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PRACTICAL  TREATISE 


MEDICAL  DIAGNOSIS 


FOR  STUDENTS  AND   PHYSICIANS. 


BY 

JOHN   H.  MUSSEK,  M.D., 

ASSISTANT    PROFESSOR    OF    CLINICAL    MEDICINE    IN    THE    UNIVERSITY    OF    PENNSYLVANIA  ;     PHYSICIAN 

TO    THE    PHILADELPHIA    AND    THE    PRESBYTERIAN    HOSPITALS  ;    CONSULTING    PHYSICIAN  TO  THE 

WOMAN'S  HOSPITAL  OF  PHILADELPHIA  AND  TO  THE  WEST  PHILADELPHIA  HOSPITAL  FOR 

WOMEN  ;  FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA  ;    MEMBER 

OF  THE  ASSOCIATION  OF  AMERICAN  PHYSICIANS  ;    PRESIDENT  OF  THE 

PATHOLOGICAL   SOCIETY  OF  PHILADELPHIA,  ETC. 


SECOND   EDITION,  REVISED  AND   ENLARGED. 


ILLUSTRATED    WITS  177  WOODCUTS  AND  11   COLORED  PLATES. 


LEA  BROTHERS  &  CO., 

PHILADELPHIA   AND    NEW  YORK, 

18  9  6. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1896,  by 

LEA    BE  OTHERS    &   CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington.     All  rights  reserved. 


P  O  R  N  A  N  .    PKINTEB, 


TO   THE 


MEMORY   OF   MY    FATHER 


BENJAMIN    MUSSER,   M.D., 


MY   GRANDFATHER 


MARTIN   MUSSER,  M.D. 


PREFACE  TO  SECOND  EDITION. 


Success  in  treatment  requires  both  accuracy  and  completeness 
in  diagnosis.  Partial  knowledge  of  the  nature  of  the  case  differs 
merely  in  degree  from  ignorance,  and  treatment  based  on  either 
invites  chances  unjust  alike  to  the  patient  and  to  the  interests  of 
the  physician. 

Diagnosis,  being  a  practical  art,  should  be  held  to  include  not 
merely  the  recognition  of  a  disease  or  a  complication  of  diseases, 
but  also  a  determination  of  the  health-value  of  the  patient.  Thus, 
in  a  case  of  pneumonia  not  only  should  the  presence  of  the  malady 
be  established,  but  the  functional  condition  of  all  the  organs  should 
also  be  investigated,  in  order  that  rational  treatment  may  be  pre- 
scribed and  a  rational  prognosis  given.  In  other  words,  the  physi- 
cian should  never  forget  that  a  patient  is  a  unit,  comprising  closely 
interacting  organs,  and  that  the  response  to  treatment  will  be  satis- 
factory in  proportion  to  its  adaptation  to  the  condition  of  the  entire 
organism.  After  twenty  years  of  experience  as  a  general  practi- 
tioner, a  hospital  physician,  and  later  as  a  consultant,  the  writer 
is  confirmed  in  the  conviction  that  success  in  treatment  follows  only 
upon  diagnosis  of  the  most  comprehensive  character,  and,  further- 
more, that  the  status  prcenens  should  be  clear  to  the  physician,  not 
only  at  the  outset,  but  also  at  every  stage  of  the  disease. 

The  first  edition  of  this  work  was  prepared  with  these  ideas  of 
completeness  in  view,  and  its  early  exhaustion  is  gratifying  as  an 
evidence  that  practitioners  and  teachers  recognize  the  vital  impor- 
tance of  complete  diagnosis,  and  have  given  their  approval  to  an 
earnest  effort  to  present  a  knowledge  of  it  in  available  form. 

This  opportunity  for  revision  has  been  conscientiously  utilized, 
and  the  new  edition  will  be  found  to  embody  the  latest  approved 
advances  and  the  newly  established  facts  and  methods  in  this  most 


viii  PREFACE  TO  SECOND  EDITION. 

active  and  practical  branch  of  medicine.  The  series  of  illustrations, 
which  was  already  unusually  large  for  a  work  of  this  character,  has 
been  enriched  with  many  new  engravings  and  colored  plates.  The 
author  can  claim  to  have  been  a  most  critical  student  of  his  own 
book,  and  likewise  to  have  profited  by  the  criticisms  of  other  teachers 
and  practitioners. 

Although  there  is  no  "royal  road"  to  diagnosis,  either  through 
compends  or  more  or  less  elaborate  catalogues  of  diseases  which  aid 
the  memory  at  the  expense  of  comprehension  and  judgment,  a 
serious  study  of  the  subject  is  repaid  in  the  acquisition  of  a  most 
valuable  power.  Modern  research  has  placed  this  fundamental 
branch  upon  the  plane  of  an  exact  science,  and  has  correspondingly 
elevated  the  whole  superstructure  of  medicine.  Instruments  and 
methods  of  precision,  physical,  chemical,  microscopical,  and  bio- 
logical, are  now  so  readily  at  the  command  of  every  practitioner 
that  he  is  legally  as  well  as  morally  bound  to  exhibit  in  his  diag- 
nosis and  treatment  a  degree  of  certainty  far  greater  than  could 
formerly  have  been  exacted. 

In  conclusion,  it  has  been  the  primary  purpose  of  this  book  to 
deal  with  the  whole  subject  of  diagnosis  in  its  present  state  of 
development  in  clear  language  and  with  abundant  illustration,  to 
afford  the  practitioner  a  consultant  upon  which  #  he  might  rely,  and 
to  present  the  facts  and  principles  in  such  a  manner  as  to  give 
the  undergraduate  and  postgraduate  student  a  rational  grasp  and 
practical  working  knowledge  of  this  fundamental  science  and  art. 

The  author  takes  this  opportunity  of  acknowledging  his  renewed 
indebtedness  to  his  friend,  Dr.  H.  B.  Allyn,  for  valuable  assistance 
while  the  work  was  going  through  the  press  ;  to  Dr.  J.  Allison 
Scott  for  the  care  and  patience  he  took  in  supervising  the  production 
of  most  of  the  drawings  and  for  suggestions  in  the  chapter  on  Dis- 
eases of  the  Kidney ;  to  Dr.  Joseph  Sailer,  Dr.  J.  Dutton  Steele, 
and  Dr.  James  Ely  Talley  for  timely  suggestions  and  great  aid  in 
verifying  references.  To  Mrs.  Philip  Putnam  Chase  the  author  is 
under  obligations  for  the  skill  and  patience  required  in  the  execu- 
tion of  many  of  the  drawings. 

1927  Chestnut  Street.  Philadelphia, 
October,  1896. 


PREFACE  TO  FIRST  EDITION. 


Modern  methods  of  medical  education  demand  that  the  student 
should  be  taught  the  expressions  of  morbid  action,  or,  in  other  words, 
the  phenomena  of  disease.  He  must  be  brought  into  contact  with 
them  in  the  hospital-ward  and  the  outpatient-room,  which  are  the 
medical  laboratories  where  all  the  data  are  collected,  analyzed,  and 
used  in  discriminating  the  various  disorders. 

The  object  of  this  volume  is  to  aid  the  student  in  the  pursuit 
of  such  laboratory-studies,  and  at  the  same  time  to  furnish  the  prac- 
titioner with  a  reliable  practical  guide  to  diagnosis  for  use  in  his 
daily  work.  It  has  been  thought  best  to  combine  in  these  pages 
the  study  of  the  objective  phenomena  or  signs  of  disease,  the  subjec- 
tive phenomena  or  symptoms,  and  the  methods  employed  for  their 
determination.  Special  attention  has  been  paid  to  research  for  objec- 
tive phenomena  appearing  in  physical,  chemical,  and  biological  changes 
in  the  tissues  and  secretions.  The  necessity  for  elaborate  descriptions 
or  extended  lists  of  minutiae  as  guides  to  differentiation  is  being  rap- 
idly displaced  by  the  use  of  instruments  of  precision.  Formerly, 
for  instance,  extensive  tables  were  displayed  to  indicate  the  differen- 
tial diagnostic  features  of  anaemia  and  chlorosis;  now  a  few  moments' 
examination  of  the  blood  decides  the  nature  of  the  affection  and 
whether  iron  or  arsenic  is  to  be  given  for  its  cure. 

The  following  pages  bear  evidence  that  the  author  does  not  under- 
value the  direct  and  collateral  data  obtained  by  inquiry.  Without 
them  an  examination  carefully  conducted  according  to  all  other 
methods  may  go  for  naught  in  the  distinction  of  disease. 

The  association  of  morbid  processes  with  their  phenomena  is  a 
practice  of  the  utmost  importance  to  students,  and  a  chapter  has  there- 
fore been  inserted  upon  the  Symptomatology  of  Morbid  Processes. 
Bacteriological  Diagnosis    has    become   an    established   method    by 


X  PREFACE  TO  FIRST  EDITION. 

which  various  disorders  are  recognized,  and  it  is  essential  that  the 
procedures  in  this  new  means  of  research  should  be  fully  outlined. 
The  chapter  on  this  subject  is  included  not  merely  as  a  guide  and 
reference  for  the  trained  student,  but  it  is  hoped  that  it  will  also 
emphasize  the  possibilities  of  bacteriological  studies  and  inspire  those 
who  are  themselves  without  facilities  for  prosecuting  laboratory-work 
to  have  examinations  made  for  diagnostic  purposes  by  experts  with 
laboratories  at  their  command. 

My  best  thanks  are  due  to  my  associate  in  private  and  hospital 
work  and  teaching,  Dr.  H.  B.  Allyn,  for  assistance  without  which 
this  book  could  not  have  been  written;  to  Dr.  H.  Toulmin  for  aid  in 
the  collaboration  of  the  sections  devoted  to  the  examination  of  Spu- 
tum and  Fseces;  to  Dr  Charles  Burr,  of  the  Infirmary  for  Nervous 
Diseases,  for  the  articles  on  Cerebral  and  Spinal  Localization  and  on 
Electrical  Diagnosis;  and  to  Drs.  Joseph  Sailer,  W.  H.  Fenn,  and 
J.  E.  Talley,  for  valuable  assistance. 

Fortieth  and  Locust  Streets,  Philadelphia, 
February,  1894. 


CONTENTS. 

PAET    I. 
GENERAL  DIAGNOSIS. 

CHAPTER  I. 

PAGES 

General  Observations 17-23 

CHAPTER  II. 
The  Data  obtained  by  Inquiry 24-48 

CHAPTER  III. 
The  Data  obtained  by  Observation 49-148 

CHAPTER  IV. 
Bacteriological  Diagnosis 149-162 

CHAPTER  V. 

The    Examination    of    Exudations,    Transudations,    and 

Cystic  Fluids 163-175 

CHAPTER  VI. 

The  Morbid  Processes  and  their  Symptomatology       .        .     176-191 


PART    II. 

SPECIAL  DIAGNOSIS. 

CHAPTER  I. 

Diseases  of  the  Nose  and  Larynx    .        .        .        .        .        .    193-227 

CHAPTER  II. 

Diseases  of  the  Lungs  and  Pleurae  .        ..       .        .        .        .    228-350 


xii  CONTENTS. 

CHAPTER  III. 

PAGES 

Diseases  of  the  Heart,  the  Bloodvessels,   and  the  Medi- 
astinum                .     351-454 

CHAPTER  IV. 

Diseases  of  the  Mouth,  Fauces,  Pharynx,  and  (Esophagus    455-492 

CHAPTER  V. 

Diseases  of  the  Stomach,  Intestines,  and  Peritoneum        .    493-621 

CHAPTER  VI. 

Diseases  of  the  Liver,  Spleen,  and  Pancreas        .        .        .     622-666 

CHAPTER  VII. 
Diseases  of  the  Kidneys 667-726 

CHAPTER  VIII. 

Diseases  of  the  Blood  and  Ductless  Glands  .        .        .     727-750 

CHAPTER  IX. 
Constitutional  Diseases        . 751-768 

CHAPTER  X. 

The  Infectious  Diseases .    769-834 

CHAPTER  XL 

Diseases  of  the  Nervous  System 835-909 


MEDICAL    DIAGNOSIS. 


PART  I, 

GENERAL  DIAGNOSIS. 


CHAPTER   I. 

GENERAL  OBSERVATIONS. 

The  data  upon  which  a  diagnosis  is  based  :  The  data  obtained  by  inquiry.  The  data 
obtained  by  observation.  -  Object  of  diagnosis. — Requirements  on  the  part  of 
the  student. — Methods  of  diagnosis:  Direct.  Indirect  (by  exclusion).  Dif- 
ferential.— Diagnosis  sometimes  impossible.  Avoid  haste. — Diagnosis  should  not 
be  limited. — Modern  diagnosis. — Case-record. — Scope  of  the  present  volume. 

The  sufferings  of  one  who  comes  under  the  care  of  a  physician  are 
indicated  by  symptoms  of  which  the  patient  himself  is  cognizant,  and 
for  which  usually  he  applies  for  relief ;  or  by  alterations  of  the  physical 
or  chemical  structure  of  the  whole  or  a  part  of  the  body,  or  of  the 
functional  activity  of  organs — alterations  which,  although  not  apparent 
to  him,  are  evident  to  the  observer,  the  physician.  The  symptoms  of 
which  the  patient  complains,  and  of  which  he  alone  has  knowledge, 
are  known  as  the  subjective  symptoms  of  disease.  The  symptoms  which 
the  physician  observes,  some  of  which,  as  the  changes  of  the  exterior, 
may  be  apparent  to  the  patient,  are  known  as  the  objective  symptoms  of 
disease. 

The  subjective  symptoms  of  disease,  as  well  as  such  objective  symp- 
toms as  the  patient  is  aware  of,  have  a  history.  It  may  be  the  brief 
one  of  sudden  onset,  or  a  long  one  of  rise  and  fall,  of  ebb  and  flow,  of 
the  mingling  of  complex  phenomena  from  time  to  time.  The  story  of 
the  evolution  of  the  disease  is  written  as  the  history  of  the  jyresent 
disease. 

The  present  disease  may  be  due  to  previous  attacks  of  disease,  or  be 
modified  by  the  occurrence  of  previous  disease.  We  may  be  consulted 
for  the  effects  of  one  link  in  a  chain  of  morbid  disorders  which  began 
in  early  infancy  or  adult  life.  We  should  learn,  therefore,  of  the 
occurrence  of  previous  disease.     Certain  types  of  constitution  and  some 

2 


18  GENERAL  DIAGNOSIS. 

few  diseases  are  transmitted  by  parents  to  offspring;  we  should,  there- 
fore, inquire  into  the  family  history.  A  further  insight  into  the  nature 
of  the  suffering  may  be  obtained  by  a  knowledge  of  the  age,  sex, 
habits,  occupation,  environment,  etc. — in  short,  by  a  knowledge  of 
the  social  history.  For,  if  the  cause  of  the  disease  under  consideration 
is  determined,  a  distinction  from  other  affections  with  allied  phenomena 
can  frequently  be  made. 

The  subjective  symptoms,  the  history  of  the  present  disease,  the  previous 
history,  the  family  history,  and  the  social  history  are  learned  by  inquiry 
of  the  patient  or  the  friends  of  the  patient  by  methods  and  within  limi- 
tations hereafter  to  be  described,  [t  is  proper  that  they  should  be 
ascertained,  if  practicable,  before  the  objective  symptoms  are  studied. 

After  the  story  of  the  patient  is  ascertained  in  lull,  the  objective  symp- 
toms are  sought  for.  Examination  of  the  patient  by  the  use  of  the 
senses  of  sight,  of  touch,  of  hearing,  with  the  instruments  of  precision 
to  aid  them — the  physical  examination — and  by  chemical  and  bacteri- 
ological methods,  reveals  the  presence  or  absence  of  the  latter  class  of 
symptoms. 

The  phenomena  of  disease  are  ascertained,  therefore,  by  inquiey  and 
by  observation.  The  facts  or  data  thus  collected  and  the  discriminate 
interpretation  of  them  constitute  diagnosis. 

Object  of  Diagnosis.  The  object  of  diagnosis  is  to  determine  the 
condition  of  the  living  patient  who  may  be  suffering  from  disease.  It 
implies  not  only  that  the  phenomena  of  disease  are  detected,  but  also 
that  the  effects  of  the  disease  on  the  organism  are  determined,  and  that 
the  morbid  process  which  is  the  cause  of  the  phenomena  is  ascertained. 
Even  this  is  too  restricted  an  idea  of  diagnosis.  It  should  include 
also  the  recognition  of  the  cause  of  the  morbid  process.  The  latter  is 
known  as  the  vetiological  diagnosis. 

Diagnosis  is  not  made  in  order  to  give  the  disease  a  name  alone,  but 
to  treat  it,  and  as  it  is  not  disease  that  we  treat,  but  a  patient  with  an 
ailment,  full  knowledge  of  the  patient  and  of  his  environment,  his 
mode  of  life,  habits,  occupation,  etc.,  must  be  obtained  by  inquiry. 

The  practical  result  of  diagnosis  is  the  ability  to  remove  or  prevent 
the  occurrence  of  the  morbid  processes,  or  to  mitigate  their  effects  by 
rational  therapeutics. 

Requisites  on  the  Part  of  the  Student.  As  data  are  to  be  col- 
lected by  inquiry  and  by  observation,  it  is  obvious  that  he  who  would 
inquire  and  observe  intelligently  and  successfully  must  be  possessed  of 
knowledge  and  qualifications  of  a  high  order.  The  phenomena  of 
health  must  be  familiar  to  him.  He  must  have  a  full  knowledge  of 
physiology  to  recognize  aberrations  of  function,  and  of  pathology  to 
understand  the  production  of  symptoms  by  disease.  He  must  know 
the  organic  results  of  pathological  processes-— morbid  anatomy.  He 
must  have  learned,  by  reading  and  experience,  the  significance  of  symp- 
toms, or  of  groups  of  symptoms,  and  their  relation  to  morbid  processes. 

He  must  have  a  knoAvledge  of  the  evolution  of  disease  and  the  phe- 
nomena of  each  period  in  its  development  to  secure  an  accurate  account 


GENERAL  OBSERVATIONS.  19 

of  the  disease  under  consideration.  He  must  know  the  influence  of 
morbid  processes  on  the  body  and  their  effect  in  the  production  of  sub- 
sequent disease,  in  order  to  ascertain  correctly  the  various  diseases  of 
the  patient  and  infer  rightly  their  relation  to  the  phenomena  under 
consideration.  The  significance  of  the  family  history  can  be  appre- 
ciated and  correctly  applied  only  by  a  knowledge  of  the  diseases  which 
are  inherited  or  which  arise  in  certain  physical  types  of  individuals, 
which  type  is  inherited.  The  social  history  is  not  worth  securing 
unless  the  inquirer  knows  the  influence  of  age  and  sex,  of  race,  of 
occupation,  of  habits,  of  residence,  of  degree  of  labor,  in  the  devel- 
opment of  disease,  or  the  influence  of  the  environment  on  the  indi- 
vidual— the  action  and  reaction  of  external  forces  on  forces  within. 

To  ascertain  the  objective  symptoms,  he  who  would  observe  properly 
must  know  anatomy  to  recognize  the  seat  of  the  disease,  and  physiology 
to  discern  the  departures  from  health.  He  must  be  trained  at  the  bed- 
side in  the  use  of  the  senses,  and  know  how  to  discriminate  and  inter- 
pret phenomena  observed  by  them.  He  must  know  how  to  use 
instruments  of  precision,  as  the  microscope,  and  must  learn  its  reve- 
lations ;  the  laws  of  chemistry  and  the  methods  of  chemical  examina- 
tion must  be  familiar  to  him.  Bacteriology  and  the  data  obtained  from 
its  methods  must  be  appreciated  fully. 

It  is  thus  seen  that  the  inquirer  must  have  knowledge  largely  gained 
by  reading  and  by  observation  at  the  bedside  and  in  the  post-mortem 
room.  He  acquires  thus,  on  the  one  hand,  the  recorded  experience  of 
others  and  learns  that  certain  symptoms  under  certain  circumstances 
indicate  a  definite  malady.  On  the  other  hand,  he  learns  that  certain 
symptoms  are  associated  with  definite  lesions. 

Methods  of  Diagnosis.  But  we  must  not  only  secure  facts,  we 
must  also  be  able  to  utilize  them  for  analysis  and  induction — the  result 
of  which  is  the  formation  of  the  diagnosis.  The  diagnosis  is  obtained 
by  three  methods — the  direct,  the  indirect,  and  the  differential.  By 
the  direct  method  the  data  collected  are  sufficient  to  warrant  a  positive 
conclusion.  An  indirect  diagnosis  is  made  by  exclusion.  A  symptom- 
group  may  represent  several  diseases.  Each  affection  is  passed  in 
review  and  excluded  until  one  is  found  to  correspond  more  closely  to 
the  data.  It  is  not  one,  because  of  the  absence  of  certain  symptoms  ; 
it  is  not  another,  because  of  the  presence  of  certain  essentially  different 
symptoms.  A  negative  is  thereby  proven.  By  the  differential  method 
the  diagnosis  of  one  of  a  few  possible  diseases  must  be  made,  the  data. 
for  and  against  which  are  passed  in  review.  The  direct  method  is 
scientific  and  the  most  satisfactory. 

Diagnosis  sometimes  Impossible.  Notwithstanding  our  efforts 
to  collect  data  by  inquiry  and  by  observation,  wrc  are  often  unable  to 
make  a  diagnosis.  This  arises  when  premises  arc  wanting  for  the 
process  of  induction.  The  subjective  symptoms  may  not  tally  with 
the  known  processes  of  disease,  or  the  narrator  of  the  history  of  the 
present  disease  may  omit  important  evidence  from  lack  of  memory  or 
knowledge,  from  design,  or  for  other  reasons.    The  objective  phenomena 


20  GENERAL  DIAGNOSIS. 

may  be  developed  in  an  ill-defined  way,  or  they  may  be  obscure,  as 
the  state  of  the  abdominal  contents  in  a  person  who  is  obese;  or  they 
may  point  to  one  or  more  processes  the  subjective  symptoms  of  which 
are  not  present.  At  the  time  of  observation  the  disease  may  not  have 
developed  fully,  may  not  have  "  spelled  itself  out."  Under  these 
circumstances  a  provisional  diagnosis  must  be  made  or  conclusions  held 
in  abeyance.  If  we  are  considering  a  contagious  disease,  for  sanitary 
reasons  all  doubt  should  be  settled  in  favor  of  the  infectious  disease. 
If,  on  the  other  hand,  the  disease  requires  prompt  remedial  action, 
the  symptoms  must  be  taken  as  the  indication  for  therapy. 

Avoid  haste.  If  prompt  action  is  not  required,  too  great  haste  should 
be  avoided.  It  is  not  necessary  to  make  a  diagnosis  at  once,  and  it  is 
not  a  confession  of  ignorance  if  time  is  asked  before  an  opinion  is  given. 
Repeated  observation  and  reflection  should  be  employed  before  a  con- 
clusion is  arrived  at.  This  particularly  applies  to  the  class  of  cases 
which  represent  a  condition  the  resultant  of  improper  environment,  for 
the  proper  detection  of  which  social  data,  knowledge  of  temperament, 
etc.,  must  be  acquired.  Then,  again,  it  may  be  necessary  to  observe 
the  patient  under  changed  circumstances,  or  study  the  effects  of  diet  on 
renal  secretion,  or  on  the  function  of  other  organs.  Haste  leads  to 
faulty  diagnosis,  and  therefore  to  misdirected  therapeusis. 

Diagnosis  should  Not  be  Limited.  It  is  not  sufficient  to  give  a 
name  to  a  group  of  symptoms,  and  be  satisfied  that  the  diagnosis  is- 
made.  Every  method  must  be  used  to  collect  data.  The  exact  phy- 
sical condition  of  the  patient  must  be  ascertained  and  the  functional 
powers  of  all  the  organs  correctly  determined.  We  thus  learn  if  the 
more  evident  disease  is  the  single  expression  of  a  morbid  process,  or  if 
it  is  the  surface-storm,  the  currents  of  which  are  underneath.  A  pleu- 
risy or  pneumonia  may  be  .the  outcome  of  or  complicate  a  latent 
nephritis.  A  peritonitis  may  be  the  sequela  of  an  appendicitis  or 
pyosalpinx.  Or  diseases  in  two  or  more  organs,  due  to  the  same  pro- 
cess, may  exist  at  the  same  time,  as  suppurative  pleuritis  and  pericar- 
ditis.     It  would  not  be  sufficient  to  recognize  the  empyema  alone. 

For  purposes  of  treatment  it  is  not  sufficient  to  recognize  a  neural- 
gia or  a  spasm.  The  state  of  the  patient  on  account  of  which  the 
neuralgia  developed  must  be  ascertained.  Attention  must  be  called 
to  the  importance  of  not  being  lulled  into  a  false  security  by  the  belief 
that  the  diagnosis  of  the  first  day  is  sufficient.  Complications  may 
arise  or  the  morbid  process  invade  new  territory.  Thus,  in  the  course 
of  pneumonia,  in  a  few  days  a  meningitis  may  arise,  or  an  ulcerative 
endocarditis  ensue. 

Modern  Diagnosis.  Anyone  who  takes  the  trouble  to  recall  the 
methods  of  diagnosis  that  were  in  use  twenty  years  ago  will  be  struck 
by  the  wonderful  expansion  of  the  means  now  at  hand  to  unravel  the 
mysteries  of  disease.  Then  a  few  instruments  of  precision  and  a  few 
chemical  reagents  were  required.  The  microscope  was  employed  to 
examine  only  a  few  of  the  excretions  and  the  blood.  Xow  the  instru- 
ments of  precision  are  multiplied  and  the  scope  of  their  explorations 


GENERAL  OBSERVATIONS.  21 

is  increased. x  Chemistry,  among  other  things,  helps  to  fathom  the  mys- 
teries of  gastric  disease.  The  microscope  has  extended  its  domain,  and, 
with  the  new  methods  of  staining  fluids  and  tissues,  has  become  the 
key  that  unlocks  many  of  Nature's  secrets.  The  new  science  of  bac- 
teriology has  come  to  our  aid,  and  now,  instead  of  waiting  to  establish 
a  diagnosis  until  an  epidemic  counts  its  victims  by  hundreds,  it  is 
obtained  at  once. 

Certainty  in  diagnosis,  for  these  reasons,  has  made  a  decided  advance. 
The  number  of  diseases  which  can  be  positively  diagnosticated  has 
increased.  Methods  of  investigation  and  new  instruments  of  precision 
are  increasing  daily.  May  we  not  hope  that  in  the  future  the  horizon 
of  absolute  knowledge  will  be  extended  far  beyond  its  present  limits? 
New  instruments  and  new  methods  will  surely  avail. 

The  use  of  the  large  number  of  instruments  that  are  essential,  and  the 
chemical  and  bacteriological  examinations  that  are  made,  require  a 
great  deal  of  time.  Often  the  diagnosis  is  a  question  of  hours  or  even 
of  days.  The  patient  profits  thereby.  The  tax  on  the  physician  is  far 
greater  than  it  was  a  few  years  ago.  The  bedside  labor  is  great,  and, 
in  addition  he  must  have  a  laboratory  at  his  command  for  microscopical, 
chemical,  and  bacteriological  work.  The  outcome  is  that  the  scientific 
physician  must  have  a  clientele  limited  in  number,  or  else  have  one 
or  more  assistants  to  aid  him  in  his  investigations.  Without  doubt 
the  latter  will  soon  occur.  Not  as  in  days  of  old  will  we  find  in  the 
practitioner's  office  the  apprentice,  compounding  drugs  and  rolling 
bandages,  assisting  in  the  operations  of  bleeding  and  dressing  ulcers, 
but  the  highly  trained,  scientific  assistant  who  by  labors  in  the  labora- 
tory and  at  the  bedside  is  competent  to  collect  data  suitable  for  scientific 
methods  of  reasoning. 

Case-records.  Records  of  cases  should  be  kept,  for  many  obvious 
reasons.  The  habit  compels  a  general  survey  of  the  case,  and  tends 
to  prevent  oversight  in  the  examination.  '  It  naturally  aids  in  the 
training  of  the  powers  of  observation.  It  teaches  precision  in  the 
narration  of  cases.  The  memory  is  aided  by  repetition  and  by  lack  of 
haste  in  ascertaining  phenomena.  The  data  are  on  record  for  more 
mature  reflection,  and  to  aid  in  the  study  of  the  literature  of  similar 
cases.  The  record  is  of  value  in  case  the  patient  returns  for  advice 
after  a  lapse  of  time.  It  may  be  of  medico-legal  value.  The  mental 
effect  on  the  patient  is  good,  for  the  taking  of  notes  requires  time  and 
accurate  studied  observation.  In  case  it  is  desired  to  study  a  large 
number  of  cases,  records  are  scientific  data.  The  records  may  be  kept 
on  loose  sheets  and  filed  for  future  use.  When  a  sufficient  number 
are  secured  they  may  be  classified  and  bound  in  volumes  devoted  to 
the  various  diseases.  Or  they  may  be  noted  in  a  blank-book.  At 
the  end  of  the  year  the  book  is  indexed  according;  to  the  diseases  and 
the  names  of  the  patients.  A  better  method  is  by  a  system  of  cards. 
The  cardboard  should  be  six  by  eight  inches.     One  card  is  devoted 

1  As  a  most  simple  illustration,  witness  the  knee-jerk  and  reflexes,  learned  by  percussion,  an  old 
method,  in  extended  use. 


22  GENERAL  DIAGNOSIS. 

to  each  case,  although  more  can  be  used.     They  are  arranged  and 
catalogued  according  to  the  library  system  of  card  catalogues. 

Method  of  Record.  .  A  systematic  plan  must  be  pursued  in  noting 
the  cases.  It  need  not  correspond  to  the  lines  of  inquiry  in  the  examin- 
ation of  the  patient,  which  are  modified  by  the  circumstances  of  the  case. 

The  social  history,  the  family  history,  previous  diseases,  the  history 
of  the  present  disease,  including  the  mode  of  onset  and  the  duration 
of  the  disease,  should  be  recorded  in  regular  sequence.  In  the  history 
of  the  present  disease  the  subjective  and  objective  symptoms  should  be 
recorded  in  order.  The  subjective  symptoms  that  refer  to  special 
systems  or  organs,  and  the  objective  symptoms  of  the  same,  should  be 
recorded  under  special  headings. 

KECORD  OF  CASE  NO.  — 

Diagnosis.  Result. 

Name  and  residence,  place  of  birth,  and  former  residence. 

Social  history. 

Age,  sex,  race,  married  or  single. 

Occupation  :     Present  and  previous. 

Habits :  Tobacco,  alcohol,  narcotics ;  sexual  habits ;  regularity  of  meals, 
character  of  food,  and  method  of  eating ;  number  of  hours  of  sleep,  degree  of 
fatigue ;  brain-use. 

Family  history :  Hereditary  tendency  ;  health  of  parents,  brothers,  sisters,  etc. 
Cause  of  death  and  age  at  which  it  occurred. 

Personal  history:     Children,  the  number  and  health  ;  miscarriages. 

Previous  diseases:  Character  of  convalescence  from  ;  syphilis  and  gonorrhoea  ; 
injuries. 

Present  disease :  Date,  mode  of  onset,  and  probable  exciting  cause  of  present 
trouble  ;  evolution  of  the  disease  to  date  of  examination. 

Present  condition :     Subjective  symptoms. 

Objective  symptoms. 

External  appearance,  development,  color,  figure,  height  and  weight,  attitude, 
expression  of  face. 

Temperature,  perspiration,  eruption,  swelling.     Condition  of  limbs  and  joints. 

Examination  of  the  digestive  apparatus:  Mouth,  tongue,  gums,  and  pharynx  ; 
abdominal  organs;  contents  of  stomach,  fseces. 

Examination  of  respiratory  apparatus :  Nose,  mouth,  and  larynx.  The  lungs ; 
inspection,  palpation,  percussion,  auscultation,  mensuration.  Cough  and  expec- 
toration. 

Examination  of  circulatory  apparatus :  Inspection  and  palpation  of  cardiac 
area;  percussion,  auscultation  of  heart ;  similar  examination  of  arteries  and 
veins,  the  pulse ;  examination  of  the  blood. 

Examination  of  the  urinary  apparatus  :  Kidneys,  ureters,  and  bladder ;  ex- 
amination of  urine. 

Examination  of  the  nervous  system, :  Intelligence,  subjective  nervous  phe- 
nomena, sleep,  gait,  station,  reflexes,  paralysis,  tremor,  pain,  convulsions,  head- 
aches, disturbances  of  sensation,  disturbance  of  speech.  The  organs  of  special 
sense. 

Examination  of  fluids  obtained  by  puncture. 

Bacteriological  examination  of  blood,  sputum,  secretions,  exudations,  etc. 

Diagnosis. 

Prognosis. 

Treatment 

Scope  of  the  "Work.  In  the  following  pages  the  data  collected 
by  inquiry  and  observation  will  be  considered,  and  the  attempt  made 


GENERAL  OBSERVATIONS.  23 

to  show  their  application  to  individual  diseases.  The  value  for 
diagnosis  of  the  social  history,  family  history,  previous  disease,  and 
history  of  the  present  disease  will  be  discussed.  The  subjective  and 
objective  symptoms  of  disease  and  the  methods  of  ascertaining  them 
respectively  will  then  be  considered.  After  the  subject-matter  above 
indicated  is  considered,  the  phenomena  or  symptoms  of  morbid  pro- 
cesses or  of  varying  causal  agencies  will  be  treated  in  a  general  way, 
in  order  that  the  student  may  have  a  general  comprehension  of  semei- 
ology. 

Classification.  This  is  based  upon  diagnostic  convenience.  No 
attempt  is  made  at  a  scientific  pathological  classification.  Diseases 
that  are  not  common  are  described  under  their  chief  objective  symp- 
toms, as  myxoedema  or  acromegaly  under  enlargement,  or  under  the 
structure  or  organs  forming  the  subject  of  objective  examination,  as 
myositis  under  muscles,  Raynaud's  disease  under  an  account  of  the 
extremities. 

The  student  can  by  ready  reference  make  practical  use  of  the  work, 
as  the  handbook  is  used  in  the  laboratory,  if  he  will  bear  in  mind  its 
plan.  He  first  obtains  data  by  inquiry,  reference  to  which  can  be  made 
under  the  appropriate  section.  Subjective  symptoms  are  included  in 
the  inquiry.  If  the  data  are  general,  they  are  considered  in  the  section 
on  general  diagnosis;  if  local,  in  the  respective  section  on  special  diag- 
nosis. Next  the  data  obtained  by  observation  are  sought.  They  are 
arranged  in  a  manner  similar  to  that  of  the  subjective  symptoms. 
Thus,  loss  of  weight  will  be  studied  in  the  consideration  of  general 
objective  symptoms;  contraction  of  the  chest,  under  diseases  of  the 
respiratory  apparatus.  An  account  of  general  phenomena,  or  those 
which  refer  to  superficial  structures,  as  the  skin,  the  eye,  or  to  general 
structures,  as  bone,  connective  tissue,  glands,  muscle,  etc. ,  can  be  found 
by  reference  to  the  body  in  general,  or  to  each  individual  structure, 
arranged  under  the  objective  symptoms.  The  phenomena  which  point 
to  an  apparatus  or  system,  as  pain  referred  to  the  chest,  for  instance, 
or  shortness  of  breath,  will  be  discussed  under  the  chapters  which  con- 
sider the  various  systems,  as  the  respiratory  or  cardiac  system  on  the 
one  hand,  or  the  digestive  on  the  other.  It  is  scarcely  necessary  to 
advise  the  student  to  consult  the  index  freely. 

There  is  nothing  more  important  to  the  student  than  to  have  a  com- 
prehensive view  of  any  subject  under  consideration.  It  is  recom- 
mended that  an  outline  be  made  of  the  subject-matter  contained  in  this 
volume.  It  can  be  done  in  small  compass,  and  if  carried  in  the  pocket 
will  be  convenient  for  review  at  odd  times.  It  is  preferable  that  the 
student  should  make  the  outline  himself,  hence  it  is  not  included  in 
the  work.  He  is  recommended  to  note  the  subjects  arranged  in. the 
index  as  headings,  and  underneath  them  to  jot  down  the  divisions  of 
the  subject  as  indicated  in  the  respective  portions  of  the  text  by  the 
sub-heads,  or  by  antique  or  italicized  words. 


CHAPTER   II. 

THE  DATA  OBTAINED  BY  INQUIKY. 

The  Social  History :  Age,  sex,  occupation,  habits,  residence  (past  and  present),  family 
relations,  exposure  to  contagion.  The  Family  History :  Parents,  grandparents, 
brothers  and  sisters  of  each — Brothers  and  sisters  of  patient — Wife  and  chil- 
dren. Previous  Diseases.  History  of  the  Present  Disease :  Duration  and  mode 
of  onset — Evolution  of  the  disease.  The  Subjective  Symptoms :  Their  value — 
Their  fallacy — Feigned  Disease — General  subjective  symptoms — Local — Pain. 

The  symptoms  of  the  disease  are  elicited  first,  so  that  at  once,  if 
necessary,  measures  may  be  directed  for  the  patient's  relief;  second, 
that  we  may  have  the  advantage  of  observation  of  the  patient's  intel- 
ligence, expression,  etc.,  and  at  the  same  time  ascertain  the  direction 
further  inquiry  should  take;  third,  in  order  that  embarrassments  may 
pass  off  and  composure  ensue  before  an  objective  examination  is  made. 
It  seems  preferable,  however,  to  begin  the  record  with  the  social  history 
of  the  case,  for  a  scientific  and  orderly  procession  in  the  data  acquired, 
and  then  proceed  to  record  the  facts  of  family  history,  previous  history, 
and  history  of  present  disease.  Certainly  it  is  immaterial  how  they 
are  considered  in  the  following  discussion,  and  for  convenience,  there- 
fore, the  above  order  will  be  followed.  It  is  to  be  remembered  that 
the  patient's  complaints  and  the  objective  phenomena — or,  if  the  patient 
is  unconscious  or  otherwise  unable  to  speak  intelligently,  the  latter 
alone — are  the  central  threads  around  which  the  diagnosis  is  woven. 

The  Social  History. 

The  aid  to  diagnosis  obtained  from  inquiry  into  the  social  history 
cannot  be  considered  exhaustively.  Works  on  hygiene  must  be  con- 
sulted. General  ideas  will  be  given;  reference  to  the  influence  of 
various  factors  will  be  found  under  the  individual  diseases.  That 
such  data  are  of  value  is  illustrated  in  various  forms  of  colic.  For 
instance,  knowledge  that  the  patient  labored  in  lead  will  often  simplify 
an  obscure  problem. 

The  Age  is  learned,  for  each  period  in  the  evolution  and  involution 
of  life  has  its  peculiar  physiological  processes  susceptible  to  variations 
by  external  influences. 

A  large  group  of  affections  arise  in  the  first  period  of  infancy,  from 
inheritance  or  congenital  malformations,  from  accidents  incident  to 
parturition,  and  from  improper  management  of  the  cord.  In  a  later 
period,  in  acquiring  adaptability  to  environment,  by  the  feebly  resisting 
organism,  disturbances  of  digestion  from  poorly  prepared  or  improper 


THE  DA TA   OBTAINED  B  Y  IX Q  UIR  Y.  25 

food  arise;  pulmonary  disorders  from  improper  clothing,  ventilation, 
etc.,  occur.  The  developing  nervous  system  has  more  acute  suscep- 
tibilities, and  hence  a  long  array  of  reflex  symptoms  or  diseases  is  ob- 
served at  this  period.  Another  group  of  diseases,  the  exanthemata, 
and  almost  all  contagious  diseases,  are  more  prevalent  in  childhood, 
because  they  arise  out  of  exposure  to  a  specific  cause  which  usually 
occurs  before  the  child  attains  many  years.  The  anatomical  arrange- 
ment of  the  larynx,  disproportionately  small,  makes  the  diseases  of 
that  organ  most  frequent  in  childhood,  and  a  serious  factor  in  mor- 
tality. 

At  puberty  we  see  the  perversions  (from  earlier  years)  liable  to 
arise  as  adolescence  advances.  Anaemia  and  chlorosis  are  prone  to 
develop  at  this  period.  In  the  middle  period,  the  diseases  that  arise 
from  occupation,  from  exposure  to  external  agencies,  from  habits,  are 
seen.  Moreover,  processes  beginning  in  adolescence  are  reaching  their 
acme,  and  find  expression  in  later  life,  as  the  cysts  of  hydatid  disease, 
or  renal  calculi,  or  manifestations  of  gout.  In  later  life  degenerations 
of  the  vascular  and  cerebro-spinal  systems  occur;  affections  due  to 
fibrosis,  a  resultant  of  wear  and  tear,  as  atheroma;  cancer;  calculous 
disease,  and  other  diseases,  prevail. 

The  Sex.  The  prevalence  of  various  diseases  in  the  sexes  in  undue 
proportion  arises  because  of  difference  in  the  anatomical  structure  and 
physiological  offices  of  the  two,  and  because  of  the  difference  in  expo- 
sure to  varying  causal  agencies.  Diseases  of  the  male  sex  occur  on 
account  of  occupation,  from  exposure,  from  over- activity  of  mind  and 
body,  and,  finally,  from  the  formation  of  bad  habits.  The  diseases  of  the 
female  sex  that  are  more  prevalent,  apart  from  their  own  peculiar 
affections  arising  out  of  menstruation  and  childbearing,  take  place 
because  of  the  more  or  less  sedentary  nature  of  their  lives,  and  hence, 
among  other  things,  the  opportunities  for  introspection.  Hysteria, 
neurasthenia,  and  nerve  disorders  abound  with  them.  Males  are  more 
subject  to  epilepsy,  gout,  diabetes,  locomotor  ataxy,  and  vesical  disease. 
Females  are  more  subject  to  exophthalmic  goitre,  rheumatoid  arthritis, 
chorea,  and  the  above-mentioned  nervous  disorders. 

Occupation.  This  must  be  ascertained  in  the  inquiry,  for  each 
occupation  demands  effort  in  one  particular  direction,  or  compels  expo- 
sure to  deleterious  influences.  Writer's  cramp,  eye-strain,  and  a  series 
of  disorders  thus  arise.  Knowledge  of  exposure  to  particular  irritants, 
coal  or  fine  particles  of  metal  or  stone,  gases,  chemicals,  effluvia  of  all 
kinds,  and  to  diseases  contracted  from  animals,  are  valuable  points  in 
diagnosis. 

The  manner  and  degree  of  employment  of  the  mind  must  be  inquired 
into. 

It  is  not  to  be  forgotten  that  the  occupation  at  different  periods  of 
life  must  be  found  out,  the  age  at  which  life's  battle  began,  and  the 
circumstances  that  surrounded  the  early  career.  The  deleterious  influ- 
ence of  a  former  occupation  may  be  observed  after  the  patient  is  in  an 
entirely  different  sphere  of  labor. 


26  GENERAL  DIAGNOSIS. 

Habits.  Habits  as  to  clothing  (catarrhal  affections  and  rheumatism), 
as  to  hours  of  rest  and  sleep  (neurasthenia),  as  to  character  of  food, 
time,  regularity,  and  manner  of  eating  (the  indigestions,  gout),  as  to 
exercise,  and  as  to  the  use  of  alcoholic  stimulants  (cirrhosis  of  the  liver, 
neuritis,  brain  affections),  of  tobacco  (amblyopia,  cardiac  palpitation), 
of  tea  or  coffee,  of  narcotics,  must  be  inquired  into.  Methods  of  work, 
methods  of  recreation,  domestic  joys  or  sorrows,  must  be  ascertained. 
A  knowledge  of  the  habits,  of  the  life — of  the  inner  life,  indeed — of 
the  individual,  is  essential  to  a  rational  diagnosis,  and  hence  a  true 
therapeusis. 

Place  of  Residence  and  Dwelling.  A  knowledge  of  the  place  of 
residence  is  of  service.  Town  residence  and  country  residence,  a  resi- 
dence in  a  damp  locality,  by  the  sea  and  in  the  mountains,  in  particular 
valleys,  in  different  watersheds,  in  tropical  or  frigid  clime,  each  makes 
an  impress  on  the  constitution,  even  if  actual  disease  is  not  created. 
Hence  malarial  regions,  goitre  districts,  localities  in  which  individuals 
have  to  an  unusual  degree  vesical  calculi,  or  in  which  special  epidemic 
diseases  abound,  as  yellow  fever,  cholera,  or  dysentery,  must  be  in- 
quired for.  Knowledge  of  the  places  of  residence  at  different  periods 
of  life  and  the  duration  of  such  is  often  important  information. 

The  situation,  and  degree  of  comfort  for  habitation,  of  the  dwelling 
must  be  learned.  The  sanitary  arrangements,  drainage,  ventilation, 
water-supply,  heating,  are  to  be  scrutinized. 

Family  Relations.  Marriage,  and  the  number  of  children,  with 
their  degree  of  health,  must  be  recorded.  If  a  woman,  the  number 
of  children  born,  the  character  of  the  labors,  the  number  of  miscarriages. 

Is  there  trouble  in  the  marital  relation  ?  Has  there  been  sorrow  or 
sudden  shock,  or  long  nursing,  or  great  care '?  Are  the  financial  cir- 
cumstances easy  ?  Has  there  been  recent  malfeasance  ?  How  many 
invalid  women  arise  out  of  such  ashes  ! 

Questions  so  personal  can  only  be  put  after  long  acquaintance,  or 
information  obtained  through  judicious  inquiry  of  friends. 

Frequently  more  delicate  questions  must  be  put,  as  to  masturbation 
or  excessive  venery,  but  with  great  caution,  and  only  when  conditions 
demand  it.  In  epileptiform  convulsions,  profound  hysteria,  neuras- 
thenia, the  development  of  locomotor  ataxy,  or  spinal  paralysis,  prompt, 
clear,  manly  questions  as  to  these  habits  are  to  be  put,  not  reference 
made  to  them  in  prudish  or  mawkish  suggestion. 

Exposure  to   Contagion.     If   the  suspected  ailment  partakes  of 
the  nature  of  a  contagious  disease,  the  probability  of  exposure  to  the 
disease  must  be  looked  into,  and  the  presence  of  epidemics  ascertained. 
The  period  of  incubation  must  be  known  in  such  cases.      The  prodro- 
mal symptoms  must  also  be  known. 

The  Family  History. 

This  inquiry  is  instituted  in  order  to  determine  the  affections  which 
may  or  may  not  be  hereditary.     We  learn  also  the  average  duration  of 


THE  DA TA  OB TAINED  B  Y  INQ  TJIR  Y,  27 

life  in  the  family,  and  the  relation  of  the  mortality  to  the  physiological 
epochs  in  life.  Data  of  the  latter  character  are  of  value  in  estimating 
the  possible  duration  of  life,  for  purposes  of  life  insurance;  and  they 
also  throw  light  on  abnormal  conditions  ;  thus  to  learn  that  most  of 
the  members  of  the  family  died  of  apoplexy  at  a  comparatively  early 
age,  or  of  aneurism  or  of  arterial  degenerations,  is  to  learn  that  vas- 
cular changes  developed  earlier  than  usual.  To  secure  accurate  data, 
the  age  and  state  of  health  of  parents,  brothers,  and  sisters,  if  living, 
are  ascertained;  or,  if  dead,  the  cause  of  death  and  age  at  which  it  took 
place.  Similar  questions  may  be  applied  to  several  generations  of  the 
family  and  to  collateral  branches. 

Concerning  the  question  of  direct  inheritance  of  disease,  but  few  are 
strictly  so.  Of  these,  nervous  diseases  are  the  most  common,  as  pro- 
gressive muscular  atrophy,  hereditary  chorea,  Thomsen' s  disease,  Fried- 
reich's ataxia,  migraine,  epilepsy,  and  forms  of  insanity.  The  writer 
has  seen  chronic  Bright' s  disease,  or  a  state  of  the  constitution  that 
predisposes  to  it,  occur  in  several  generations  without  the  usual  excit- 
ing causes  of  that  affection.  Syphilis  may  be  inherited.  Hsemophilia 
is  the  most  striking  affection  that  is  transmitted  by  inheritance.  Gen- 
erally it  is  not  the  diseases  themselves  that  are  hereditary,  but  types 
of  tissue  that  predispose  to  disease,  as  in  tuberculosis,  or  cancer;  or 
conditions  of  the  organism  that  favor  imperfect  metabolism,  as  is  seen 
in  gout  or  rheumatism. 

The  family  physician,  who  comes  in  contact  with  one  or  more  gener- 
ations, profits  most  by  the  knowledge  of  the  family  history.  He  learns 
the  predisposition  to  various  minor  ailments — to  headaches  and  attacks 
of  indigestion,  "  bilious  attacks,"  for  instance;  he  learns  the  power  of 
resistance  to  disease  in  the  family,  or  their  capability  to  undertake  large 
duties  in  life;  he  learns  their  susceptibility  to  drugs,  and  their  tendency 
to  take  stimulants.  Nerve-force  is  the  capital  with  which  the  battle 
of  life  is  kept  up.  If  it  is  at  a  minimum  in  groups  of  families,  dis- 
eases or  conditions  of  poor  health  due  to  its  use — a  use  not  excessive 
in  others — arise. 

In  the  inquiry,  it  may  be  well  to  ascertain  the  probability  of  disease 
being  transmitted  from  husband  to  wife,  or  the  opposite.  Syphilis  and 
gonorrhoea,  and  tuberculosis  are  examples.  Not  only  may  this  proba- 
bility apply  to  the  transmission  of  disease  from  husband  to  wife,  but 
to  its  transmission  along  lines  of  families.  Then,  too,  we  must  inquire 
of  mothers  for  the  manifestations  of  syphilis  in  the  children. 

Caution  must  be  exercised  in  the  pursuit  of  knowledge  of  this  kind, 
as  strained,  or  even  ruptured,  marital  relations  may  result  from  injudi- 
cious intimations. 

Caution  must  be  employed  in  order  not  to  arouse  family  pride  if  evi- 
dence of  "  scrofula"  is  sought  for,  or  to  provoke  undue  alarm  when 
inquiry  into  the  family  history  of  cancer  is  made.  Disarm  suspicion 
by  inquiring  for  the  symptoms  of  the  disease  in  various  organs  in 
which  it  may  occur,  as  jaundice,  uterine  hemorrhage,  etc.,  or  ask 
about  growths  or  tumors.  Do  not  use  the  specific  terms,  consumption 
and  cancer. 

Moreover,  care  must  be  exercised  to  secure  definite  data,  not  to  over- 


28  GENERAL  DIAGNOSIS. 

estimate  statements  as  to  the  cause  of  death  being  "  dropsy,"  or 
"  jaundice,"  or  "  cold,"  or  "  teething,"  or  "  change  of  life."  Con- 
trol-questions must  be  put  by  inquiry  into  the  character  of  the  symp- 
toms that  attended  the  fatal  illness,  and  by  giving  the  affections  the 
various  popular  names  that  are  given  them  in  different  countries. 

The  data  of  the  family  history  are  of  no  avail  unless  it  is  remembered 
that  many  fundamental  affections  have  various  modes  of  expression. 
Various  diseases  may  be  allied  to  the  one  suspected  to  exist  in  the  patient, 
and  be  overlooked  because  of  this  difference  of  expression.  One  member 
of  a  family  may  die  of  heart  disease,  another  of  rheumatism,  or  some 
have  had  chorea,  or  cutaneous  affections,  or  renal  calculi;  such  ailments 
are  expressions  of  the  same  morbid  process.  Finlayson  well  puts  them 
into  groups  and  fittingly  portrays  them  as  follows  :  "In  regard  to  scrof- 
ulous [tuberculous]  diseases,  we  ask  for  swollen  glands  or  '  waxen  ker- 
nels,' or  running  in  the-  neck,  diseases  of  the  spine  and  other  bones, 
bad  joints,  white  swellings,  or  '  incomes '  as  they  are  termed  in  Scot- 
land; disease  of  the  glauds,  of  the  bowels,  water  in  the  head,  con- 
sumption of  the  lungs,  or  decline,  or  weakness  of  the  chest  with 
spitting  of  blood,  and  so  on. 

"  Heart  disease,  rheumatism,  chorea,  psoriasis,  and  some  other  cuta- 
neous affections,  and  perhaps  renal  concretions  and  emphysematous 
bronchitis,  appear  to  replace  each  other  in  different  members  of  the 
same  family. 

"  The  neurotic  group  includes  the  various  forms  of  neuralgia,  epi- 
lepsy, hypochondriasis,  hysteria,  and  insanity;  apoplexy  and  hemiplegia 
may  (perhaps  doubtfully)  be  included  in  this  group;  their  hereditary 
character  seems  rather  to  be  associated  with  vascular  disorders.  Gout, 
disease  of  the  liver,  contracted  kidney,  renal  calculus  and  gravel,  and 
angina  pectoris  form  another  allied  group;  and  these  have  also  some 
affinity  with  the  disorders  connected  with  arterial  degenerations.  Syph- 
ilis, which,  of  course,  has  marked  hereditary  characters,  assumes  such 
a  multitude  of  forms  as  to  preclude  enumeration;  but  the  tendency  is 
for  such  syphilitic  diseases  to  fail  in  the  course  of  time  from  early  death 
or  sterility.  Abortions,  stillbirths,  early  deaths  in  infancy  associated 
with  cutaneous  eruptions  on  the  buttocks,  and  with  snuffles,  are  im- 
portant in  many  family  histories;  nervous  deafness,  opacities  of  the 
cornea,  notched  teeth,  epilepsy,  and  imbecility  are  occasional  manifes- 
tations of  the  same  disorder  in  those  children  who  survive." 

It  is  thus  seen  that  in  securing  the  family  history  data  are  acquired 
which  may  be  (1)  complete  and  of  value  in  estimating  family  tenden- 
cies; or  (2)  vague  and  of  doubtful  value.  The  latter  is  due  to  lack  of 
memory  on  the  patient's  part,  or  to  his  ignorance  of  technical  terms. 
The  difficulties  must  be  overcome  by  control-questions  prompted  by 
our  knowledge  of  the  nature  of  the  disease  and  its  frequency  at  differ- 
ent ages,  by  an  inquiry  for  symptoms,  and  by  investigation  into  col- 
lateral and  remote  branches  of  the  family. 

The  fact  that  diseases  skip  a  generation  (atavism)  must  be  remem- 
bered. A  generation  may  be  small  or  decimated  by  accidental  dis- 
ease, and  hence  the  force  of  the  family  history  be  weakened.  At 
times  in  a  family  sufficient  time  has  not  elapsed  for  predisposition  to 


THE  DATA  OBTAINED  BY  INQUIRY.  29 

arise,  as  when  we  inquire  into  the  illness  of  a  child  whose  parents  are 
in  early  adult  life.  Finally,  all  negative  facts  must  be  recorded.  Such 
knowledge  must  act  as  a  control-element  in  estimating  the  value  of  the 
family  history. 

Previous  Disease. 

The  remote  effects  of  disease,  and  of  its  sequelae,  as  impressed  on 
the  organism,  make  it  essential  to  inquire  into  the  nature  of  the  pre- 
vious diseases  of  the  patient  whom  we  are  studying.  The  date  and 
character  of  the  disease,  the  duration,  the  degree  of  severity,  and  the 
completeness  of  convalescence  must  be  determined. 

Many  diseases,  as  the  exanthemata,  usually  occur  but  once  in  the 
same  person,  and,  therefore,  in  the  diagnosis  of  obscure  cases,  if  a  his- 
tory of  their  occurrence  has  been  ascertained,  they  can  be  excluded  in 
the  count.  Others  recur  from  time  to  time,  as  croupous  pneumonia, 
chorea,  acute  rheumatism,  and  tonsillitis.  The  history  of  a  previous 
attack  of  a  certain  disease  may  point  to  the  nature  of  a  second  attack 
which  otherwise  may  be  obscure.  Some  diseases,  as  rheumatism,  syph- 
ilis, and  gonorrhoea,  have  pronounced  sequelae.  Knowledge  of  the 
occurrence  of  the  primary  disease  may  solve  doubts  as  to  the  nature  of 
the  sequelae. 

Infectious  diseases  lead  to  forms  of  neuritis  and  to  brain  affections, 
or  to  inflammations  of  organs.  The  seat  of  the  specific  inflammatory 
process  varies  in  different  diseases;  after  measles  we  find  the  mucous 
membranes  impressionable;  after  scarlet  fever,  the  serous  membranes, 
the  ears,  and  kidneys  liable  to  inflammation.  The  history  of  an  attack 
of  hepatic  or  renal  colic  may  point  to  the  diagnosis  of  an  otherwise 
obscure  process  in  the  liver  or  kidney. 

The  history  of  injury  must  be  sought  for  in  brain  and  spinal  affec- 
tions. The  occurrence  of  a  surgical  operation  in  the  past  may  point 
to  lesions  for  which  it  was  resorted  to,  which  again  may  be  the  source 
of  disease. 

The  History  of  the  Present  Disease. 

Scope  of  Inquiry.  The  history  of  the  present  disease  includes  an 
account  of  the  sufferings  of  the  patient,  which  I  have  said  are  the  .sub- 
jective symptoms,  of  the  duration  of  the  disease,  of  its  mode  of  onset, 
and  of  the  evolution  of  its  symptoms  up  to  the  time  it  was  seen  by  the 
physician.  The  patient  also  gives  an  account  of  such  objective  symp- 
toms as  could  be  noted  by  him,  as  swelling  of  the  legs,  the  date  of  its 
commencement,  mode  of  onset,  and  progress.  In  the  case-record  the 
history  to  the  elate  of  examination  is  first  recorded,  and  then  the  sub- 
jective symptoms  are  noted.  The  same  order  will  be  followed  in  the 
text.  Practically,  it  is  better  to  learn  the  symptoms  on  account  of 
which  the  patient  applied  for  treatment,  and,  with  them  as  a  guide, 
to  inquire  into  the  date  of  origin  and  mode  of  development  of  the 
disease. 

Method  of  Inquiry.  The  history  and  subjective  symptoms  are 
best  learned  in  the  language  of  the  patient.      If  the  memory  fails  or 


30  GENERAL  DIAGNOSIS. 

the  symptoms  are  not  clearly  narrated,  judicious  questions  will  suffice 
to  complete  the  story.  Leading  questions  must  not  be  put  until  the 
patient's  own  account  is  lully  given. 

Often  the  patient  will  be  too  voluble  and  introduce  irrelevant  matter, 
or  too  taciturn  from  modesty  or  a  desire  to  conceal  facts,  as  when 
illegitimately  pregnant.  While  much  time  is  lost  in  listening  to  a 
prolix  account  of  sufferings,  the  student  will  do  well  at  first  to- 
bear  with  the  patient,  for  it  gives  him  the  opportunity  to  study  char- 
acter, observe  the  mental  and  emotional  characteristics  of  the  patient 
and  the  expression  of  the  countenance.  To  suppress  the  loquacious, 
free  the  tongue  of  the  silent,  gather  scintillations  of  intelligence  out 
of  the  dense  clouds  of  ignorance,  require  knowledge  of  human  nature 
of  a  high  degree,  acquired  only  by  long  practice.  (Allied  difficulties 
have  been  discussed  in  the  paragraphs  devoted  to  the  family  history.) 
Indeed  the  wonderful  faculty  of  seeking  information  in  this  manner 
has  been  the  capital  of  many  physicians  of  large  practice.  It  is  by 
this  means  and  by  tricks  that  the  charlatan  plies  his  vocation.  A 
favorite  method  of  the  quack,  after  a  few  words  from  the  patient,  is 
to  tell  him  how  he — the  patient — feels.  They  have  some  knowledge 
of  the  march  of  disease,  and  portray  its  full  development  to  the  sur- 
prised and  credulous  victim.  Elsewhere  (see  Subjective  Symptoms) 
the  reliability  of  such  data  is  discussed,  and  the  student  must  not  for 
one  moment  consider  the  data  obtained  by  inquiry  as  of  equal  value 
with  those  obtained  by  observation;  the  former  is  the  mere  skeleton 
of  the  diagnosis. 

It  is  particularly  important  to  secure  the  chronological  order  of 
events  in  the  disease.  They  are  essential  and  logical,  and  throw  much 
light  on  the  progress  of  the  affection,  and  the  diagnosis  is  much  easier 
if  such  sequence  is  followed.  Of  course,  there  are  circumstances  when 
only  the  minimum  amount  of  information  of  this  character  can  be 
secured.  The  patient  may  be  unconscious,  or  in  a  convulsion,  or 
unable  to  speak  from  dyspnoea.  It  then  becomes  necessary  to  rely  on 
the  testimony  of  friends  or  to  gather  the  information  from  the  circum- 
stances that  surround  the  patient. 

Mode  of  Onset  and  Duration  of  the  Disease.  It  is  well  to 
learn  if  the  onset  of  the  disease  was  sudden  or  gradual.  If  the  former, 
the  most  striking  phenomena  are  to  be  ascertained — a  chill,  convulsion, 
sudden  pain,  sudden  vomiting,  a  profuse  diarrhoea;  each  points  to  lines 
of  further  inquiry.  If  the  latter,  did  it  follow  upon  an  acute  illness,  or 
did  each  symptom  gradually  increase  in  intensity,  and  as  each  week  or 
each  month  passed  by  new  phenomena  creep  into  the  symptom-complex. 
We  thus  learn  if  the  affection  under  consideration  is  acute  or  chronic — 
its  duration.  It  must  not  be  forgotten  that  certain  affections  may  be 
two  or  three  days,  or,  on  the  other  hand,  as  many  weeks  in  developing, 
as  typhoid  fever,  which,  nevertheless,  is-  acute.  It  must  be  remem- 
bered also  that  diseases  may  have  sudden  acute  expressions,  and  that 
a  chronic  disease  may  be  in  existence  a  long  time  without  the  patient's 
knowledge.  An  acute  colliquative  diarrhoea  or  a  convulsion  is  often 
the  first  intimation  of  a  chronic  nephritis;  an  attack  of  angina  pectoris, 


THE  DATA  OBTAINED  BY  INQUIRY.  31 

the  first  symptom  of  organic  heart  disease  of  long  standing.  To 
appreciate  the  relationship  of  acute  to  chronic  disease,  or  of  acute 
phenomena  to  chronic  morbid  processes,  requires  a  full  knowledge  of 
the  processes  of  disease. 

Evolution  of  the  Disease.  In  making  inquiry  concerning  the 
evolution  of  the  subjective  symptoms  complained  of,  the  frequency, 
duration,  character,  and  degree  of  severity  of  each  symptom,  and  its 
relationship  to  the  function  of  the  organ  apparently  affected,  must  be 
inquired  into.  Thus  in  the  case  of  pain  in  the  abdomen,  we  must 
learn  its  character,  its  frequency,  its  duration,  its  intensity  and  its  loca- 
tion, and  whether  associated  with  functional  disturbance  of  any  of  the 
viscera  in  which  the  pain  presumably  has  its  origin.  Or,  if  there  is 
frequency  of  micturition,  the  length  of  time  the  symptom  has  been  pres- 
ent, the  degree  of  frequency,  the  time  in  the  twenty-iour  hours  when  the 
micturition  is  most  frequent;  its  relation  to  food,  exercise,  or  emotions; 
the  character  of  the  act  of  micturition,  and  its  association  with  other 
evidences  of  functional  disorder  in  the  genito-urinary  tract,  or  of 
organic  changes  in  the  urinary  apparatus. 

Having  ascertained  the  full  story  of  the  patient,  including  all  data 
obtained  by  inquiry,  special  attention  must  be  paid  to  the  sufferings 
or  complaints  of  the  moment.  They  must  be  further  inquired  into  in 
the  manner  above  indicated.  It  may  be  they  were  detailed  in  the 
beginning;  but  information  obtained  from  an  account  of  the  evolution 
of  the  disease  or  the  previous  history  will  require  a  repetition,  with  the 
putting  of  fresh  questions  or  control-questions.  Having  obtained  the 
chronological  account  of  the  factors  of  life  and  of  disease  we  are  pre- 
pared to  examine  into  the  significance  of  subjective  symptoms. 

The  Subjective  Symptoms, 

The  subjective  symptoms  are  expressive  of  the  sensations  of  the 
patient,  and  vary  in  accordance  with  the  sensibilities  of  the  individual 
affected.  Thus  acute  pain  may  apparently  represent  a  severe  process 
in  one,  while  in  another  the  same  severity  of  process  may  be  repre- 
sented by  the  minimum  amount  of  pain.  It  is  well  known  that  indi- 
viduals of  one  nationality  bear  pain  with  greater  fortitude  than  individ- 
uals of  another. 

So,  individuals  vary  not  only  as  to  pain-sense,  but  as  to  other  sub- 
jective symptoms.  The  morale  is  shattered  in  some  more  readily  than 
in  others;  thus,  for  instance,  oppression  of  the  prrecordia  may  strike 
terror  to  some,  while  to  others  it  would  be  simply  a  sense  of  discomfort. 
Moreover,  subjective  symptoms  are  constantly  before  the  patient,  while 
in  distress,  if  only  in  the  mind's  eye,  and,  because  of  his  perturbed 
state,  grow  in  magnitude  rather  than  diminish.  We  must  study  them 
from  many  points  of  view.  The  mode  of  onset,  frequency,  degree, 
and  character  of  the  symptoms  must  be  inquired  into.  The  compe- 
tency of  the  witness  under  the  circumstances,  from  lack  of  accurate 
noting  of  symptoms,  failure  of  memory,  varying  degree  of  suscepti- 
bility to  impressions,  etc.,  may  well  be  doubted.      But  not  only  does 


32  GENERAL  DIAGNOSIS. 

the  varying  "  personal  equation"  of  the  patient  render  subjective 
symptoms  fallacious  ;  the  same  factor  in  the  physician  contributes  to 
the  fallacy.  The  latter  may  have  unfortunately  formed  by  hearsay 
regarding  the  patient  a  preconceived  notion  of  the  nature  of  the  disease; 
or  from  personal  bias  in  favor  of  particular  diseases,  on  account  of 
narrow  lines  of  study  or  lack  of  breadth  of  view  of  pathological  pro- 
cesses, he  may  set  out  to  prove  a  theory  rather  than  to  establish  a  tact. 
In  either  case,  by  leading  questions,  by  placing  emphasis  on  certain 
parts  of  the  testimony,  the  subjective  symptoms  can  be  juggled  with 
and  made  to  tell  any  but  the  truthful  story. 

It  is  to  be  remembered  that  it  is  our  province  not  only  to  ascertain 
the  cause  of  suffering  in  the  sick,  but  also  to  detect  the  flaws  in  the 
testimony  of  him  who  would  feign  sickness.  The  malingerer  utilizes 
subjective  symptoms  to  hide  his  deception  because  they  cannot  be  seen, 
felt,  weighed,  measured,  or  ascertained  by  hearing. 

Feigned  Disease.  To  detect  feigned  sickness  demands  much  acu- 
men on  the  part  of  the  physician.  He  must  not  only  be  able  to  make 
an  accurate  and  exhaustive  objective  examination  of  the  patient,  but 
be  alert  to  appreciate  surroundings  and  conditions.  Feigning  may  be 
suspected  if  there  is  a  motive,  as  in  the  case  of  prisoners,  pension  appli- 
cants, students  at  school  or  college,  persons  who  hold  policies  of  insur- 
ance indemnifying  in  case  of  sickness.  The  hospital  "  beat "  thus 
plays  upon  charity.  If  sickness  recurs  frequently  without  definite 
cause,  while  the  subjective  symptoms  are  mild  and  quickly  relieved  and 
the  objective  symptoms  negative,  the  use  of  instruments  of  precision 
will  detect  the  malingerer.  With  their  aid  we  can  usually  find  out  if 
the  subjective  and  objective  phenomena  tally.  The  failure  of  such 
tally  proves  the  deception.  The  thermometer  frequently  exposes  the 
deception,  as  fever  can  rarely  be  simulated,  although  tricks  with  the 
thermometer  may  be  carried  on.  A  favorite  method  is  to  rub  it,  and 
thus  cause  the  mercury  to  rise.  Frequently  the  suspected  person  must 
be  placed  under  close  surveillance,  unknown  to  him,  and  tricks  of  all 
sorts,  suggested  by  the  surroundings  and  circumstances,  played  upon 
him  to  make  him  unwittingly  testily  to  his  deception. 

The  student  will  learn  later  that  there  is  a  mimicry  of  disease,  and 
that  in  certain  nervous  affections  the  simulation  of  subjective  symptoms 
is  its  chief  role.  In  hysteria,  subjective  and  objective  symptoms  are 
masked.  Long  experience  and  acumen  are  required  by  the  physician 
to  unmask  the  deceptions.  The  age  of  the  patient,  the  sex,  the  state 
of  the  emotions,  the  varying  expressions  of  the  symptoms  (under  vary- 
ing circumstances) — with  attention  fixed  or  removed,  the  mobility  of 
the  symptoms  under  excitement  or  emotional  disturbance,  tile  lack  of 
harmony  between  functional  disorder  and  organic  change,  are  the  ele- 
ments to  be  considered  in  order  to  fathom  the  mysteries.  Often  anaes- 
thesia must  be  induced  in  order  to  dissipate  simulated  tumors,  relax 
rigid  joints  or  contracted  limbs.  Magnetism,  electricity,  and  other 
tests  are  likewise  employed.  In  the  chapter  on  Hysteria  its  manifold 
expressions  will  be  adverted  to,  and  it  will  be  seen  that  functional 
disorder  of  almost  every  organ  or  special  sense  is  simulated  in  this 


THE  DATA  OBTAINED  BY  INQUIRY.  33 

affection.  Organic  processes  even  are  imitated,  as  joint-inflamma- 
tions, peritonitis,  and  other  grave  conditions. 

Notwithstanding  the  fallacy  of  subjective  symptoms  in  that  they 
may  be  feigned  or  mimicked,  they  are  valuable  evidences  in  the  hands 
of  the  scientific  inquirer.  If  the  patient  is  a  good  witness,  their  value 
is  much  enhanced.  He  must  be  intelligent  and  truthful.  His  testi- 
mony is  of  value  if  he  can  array  in  logical  order  the  sequence  of  symp- 
tomatic events  which  culminated  in  the  condition  for  which  he  seeks 
relief.  If  he  can  clearly  narrate  the  events  in  his  past  life,  or  in  the 
lives  of  his  ancestors,  which  appertain  to  physiological  aberrations,  his 
story  is  an  aid  to  the  searcher  for  truth. 

If,  with  this,  the  doctor  is  possessed  with  a  scientific  turn  of  mind, 
considering  evidence  without  allowing  previous  conceptions  to  influence 
him,  capable  of  discerning  the  truth  and  discarding  the  false,  of  anal- 
yzing and  weighing  statements,  and  of  appreciating  their  relationship 
to  what  is  known  of  morbid  processes,  the  patient's  statements  of  sub- 
jective symptoms  are  of  value  in  the  discernment  of  disease. 

The  Nature  of  the  Subjective  Symptoms.  The  symptoms  of 
which  the  patient  complains  may  be  general  or  local.  The  former  will 
be  briefly  considered  in  this  section;  the  latter  will  be  discussed  in  the 
respective  sections  devoted  to  disease  of  the  various  organs  to  which 
the  subjective  symptoms  refer.  They  are  symptoms  due  to  functional 
disturbances  of  the  respective  system  that  is  the  seat  of  disease,  as  dysp- 
noea or  cough  in  diseases  of  the  respiratory  system,  anorexia  or  nausea 
in  diseases  of  the  digestive  system.  An  exception  will  be  made  in 
the  case  of  pain.  While  there  may  be  such  general  suffering  as  to 
constitute  pain  (general  soreness,  aching,  rhachialgia),  yet  the  symp- 
tom has  its  point  of  origin  most  frequently  in  some  local  disorder. 
Notwithstanding  this  fact,  however,  as  it  is  a  symptom  common  to  so 
many  affections,  and  as  general  rules  apply  to  the  recognition  of  its 
multitudinous  forms,  a  brief  section  will  be  devoted  to  its  study. 

General  Subjective  Symptoms.  The  general  subjective  symp- 
toms— that  is,  the  abnormal  and  disagreeable  sensations  which  extend 
more  or  less  over  the  whole  body,  or  are  referable  to  more  than  one 
organ  or  apparatus — are  few  in  number  and  are  not  diagnostic  of  any 
particular  affection.  They  are  at  times  the  only  symptoms  complained 
of  by  the  patient,  and  require  investigation.  They  include  abnormal 
sensations  of  strength  or  weakness,  general  numbness  or  tingling,  and 
general  paresthesia?  of  all  kinds;  general  vasomotor  disturbance,  caus- 
ing sensations  of  heat,  such  as  occur  in  flashes,  or  sensations  of  cold, 
from  mild  chilliness  or  "creeps"  to  the  pronounced  chill  or  rigor, 
sudden  perspirations,  general  throbbings  or  pulsations,  and  general 
discomfort,  to  which  the  term  nervousness  is  applied.  Irritability, 
disorders  of  sleep,  and  the  more  distinct  nervous  manifestations  above 
mentioned  will  be  referred  to  in  sections  on  nervous  disease,  and  par- 
ticularly discussed  under  Hysteria,  and  Neurasthenia. 

A  feeling  of  strength,  or  the  idea  of  an  ability  to  perform  great 
feats  of  strength  or  endurance,  or  a  great  mental  feat,  is  a  subjective 

3 


34  GENERAL  DIAGNOSIS. 

symptom  that  is  dwelt  upon  by  the  patient  who  is  developing  or  passing 
through  certain  stages  of  paretic  dementia.  It  is  accompanied  by  other 
evidences  of  exhilaration.  Exhilaration  attends  chlorosis  and  forms  of 
hysteria  and  neurasthenia,  the  physical  or  mental  exhibition  of  strength 
taking  place  in  the  after  part  of  the  day  and  evening,  or  upon  undue 
excitement.     Corresponding  depression  usually  follows. 

A  sense  of  weakness,  or  exhaustion,  or  of  fatigue  is  often  complained 
of.  If  an  absolute  demand  is  made  upon  the  bodily  strength,  it  can 
respond,  but  otherwise  it  is  not  exerted.  The  patient  complains  of 
being  more  tired  in  the  morning  than  upon  retiring,  or  of  a  sense  of 
inability  to  perform  accustomed  or  special  duties.  Mental  depression 
usually  attends  the  phenomenon.  It  is  due  to  neurasthenia  generally, 
but  is  a  frequent  accompaniment  of  and  dependent  upon  the  forms  of 
toxaemia  to  which  malaria,  gout,  and  rheumatism  belong;  of  the  tox- 
aemia of  certain  varieties  of  indigestion,  of  tobacco,  alcohol,  and  other 
narcotic  poisons  (tea  or  coffee),  and  of  mineral  poisons.  The  same  sense 
of  fatigue  attends  the  prodromal  stage  of  the  specific  fevers.  It  has 
been  a  symptom  observed  frequently  of  late  in  the  sequential  period 
of  influenza. 

The  sensation  of  weakness  must  not  be  confounded  with  true  weak- 
ness or  muscular  prostration.  While  the  patient  is  aware  of  its  pres- 
ence, it  is  well  to  consider  it  under  the  objective  phenomena  of  disease, 
for  it  is  a  readily  recognized  sign  of  disease. 

Numbness,  or  tingling,  or  burnings  may  be  general  or  local.  It  is  a 
common  form  of  paresthesia,  to  be  discussed  in  the  section  on  'nervous 
diseases.  It  must  be  remembered  that,  while  a  disorder  of  sensation, 
it  is  due  to  morbid  conditions  outside  the  pale  of  the  nervous  system. 
It  may  be  of  reflex  origin,  from  irritation  at  a  distant  point,  or  it  may 
be  and  usually  is  due  to  a  toxaemia,  as  lithaemia.  Other  subjective 
vasomotor  disturbances  that  are  of  frequent  occurrence  are  likewise 
manifestations  of  nerve-disorder  from  reflex  or  toxic  causes.  Flush- 
ings, and  a  constant  sensation  of  heat  with  or  without  perspiration, 
which  attend  the  perturbation  of  the  menopause,  are  common  in 
uterine  disorders  and  in  chronic  gastritis. 

The  student  will  learn  that  the  curious  manifestations  to  which  refer- 
ence has  been  made  are  all  evidences  of  ill  health,  of  a  depressed 
vitality,  of  a  condition  in  which  there  are  malnutrition,  poverty  of 
nerve-force,  and  lack  of  blood-richness  (anaemia).  There  may  be 
peripheral  irritation  or  a  toxaemia,  but  the  under-current  of  ill  health 
is  the  fundamental  derangement. 

Chill  and  fever.  Both  are  subjective  as  well  as  objective  phenomena, 
but  as  one  can  be  accurately  estimated  by  an  instrument  of  precision 
(thermometer),  and  as  both  are  generally  associated,  the  discussion  of 
them  will  be  postponed.     (See  Objective  Signs.) 

The  abnormal  sensation  of  cold  or  of  heat  will  be  discussed  in  the 
chapter  on  Nervous  Diseases. 


THE  DA  TA  OB TAINED  B  Y  INQ  UIB  Y.  35 


Pain.1 

Definition.  Pain  is  a  general  term  used  in  medicine  to  describe  a 
number  of  subjective  symptoms  connected  with  morbid  processes.  It 
may  be  defined  as  a  sensation  which  produces  on  the  part  of  the  organ- 
ism, as  a  whole,  the  desire  to  abolish  or  escape  from  it.  Usually  it  is 
the  expression  in  consciousness  of  injury  to  the  peripheral  nervous  sys- 
tem; at  times  the  central  end  of  the  peripheral  nerves  may  be  the 
seat  of  irritation,  causing  so-called  referred  pains.  This  definition, 
however,  fails  to  include  the  hyperesthesias,  the  hyperalgesias,  and 
all  simulated  pains.  But  the  latter  are  to  be  included  in  this  section, 
on  the  ground  of  clinical  convenience;  whilst  the  two  former  are  only 
of   significance  as  conducing  to  the  production  of  pain. 

Pathology.  The  pathology  of  pain  is  generally  believed  to  be  a 
state  of  impaired  nutrition,  and  hence  of  injury,  gross  or  microscopic, 
either  at  the  periphery  or  in  the  afferent  nerve  tract.  The  cause  may  be 
purely  functional,  as,  for  example,  when  pain  is  due  to  the  over-stimula- 
tion of  the  tract  by  its  normal  stimulus,  and  its  consequent  exhaustion ; 
or  to  strictly  local  conditions,  as  pressure,  injury,  or  inflammation;  or  to 
systemic  conditions  acting  locally,  as  the  neuralgias  of  ansemia.  There 
is  also  the  so-called  sympathetic  or  reflex  pain,  due  to  irritation  in  a 
part  removed  from  the  locality  to  which  the  sensation  is  referred.  In 
certain  cases  of  neuralgia  the  nature  of  the  disturbance  has  not  been 
ascertained. 

Variations  in  Disease.  Pain  is,  perhaps,  the  most  variable  symp- 
tom in  disease.  It  ranges  from  a  sensation  of  mere  discomfort,  as  the 
dull  ache  of  chronic  lumbago,  to  the  stabbing  pain  of  pleurisy,  or  the 
intolerable  anguish  of  heart-pang.  It  is  at  times  compatible  with  the 
highest  mental  endeavor  or  the  severest  physical  exertion,  or  the  whole 
energy  of  the  organism  is  absorbed  in  resisting  it.  It  may  be  definitely 
localized  in  any  part  of  the  body,  in  any  of  the  tissues,  or  distributed 
over  an  ill-defined  area. 

The  Recognition  of  Pain.  The  Mode  of  Expression.  As  a 
rule,  the  physician  learns  of  its  existence  by  communication  from  the 
patient.  Thus  he  learns  more  or  less  accurately  its  location,  character, 
degree,  and  duration;  and  usually  something  concerning  its  causation. 
But  the  value  of  this  source  of  information  is  variable.  The  patient 
may  be  voluble  and  describe  too  much;  or  taciturn  and  admit  too  little; 
or  ignorant  and  unable  to  give  a  clear  account.  Fortunately,  there  are 
other  ways  by  which  suffering  is  expressed,  (a)  Facial  expression,  the 
most  common  interpreter  of  the  emotion,  is  far  more  reliable.  The 
tense  and  drawn  lineaments,  the  clinched  jaws,  the  dilated  pupils,  the 
livid  countenance  make  a  picture  of  agony  which,  with  the  labored 

1  Paiu  is  treated  in  a  suggestive  manner,  and  so  much  space  given  to  it  because  it  is  too  fre- 
quently improperly  managed.  Its  cause  is  never  thoroughly  investigated.  Anodynes  are  given 
for  its  relief,  thus  too  frequently  creating  victims  of  the  morphine-,  chloral-,  or  other  habit.  The 
following  articles  are  suggestive  :  On  disturbances  of  sensation  with  especial  reference  to  the  pain 
of  visceral  disease.  Head:  Brain,  vol.  xvi.,  Part  I.,  1893;  Ross  :  Brain,  1888;  Mackenzie:  Med- 
ical Chronicle,  1SS8 ;  Mackenzie :  Points  Bearing  on  the  Association  of  Sensory  Disorders  and 
Visceral  Disease.  Brain,  vol.  xvi.,  Part  III.,  1S93.  Also,  papers  by  Starr.  See  Section  on  Nervous 
Disorders. 


36  GENERAL  DIAGNOSIS. 

respiration,  the  general  shrinkage  of  the  body,  are  unmistakable  (see 
Chapter  III.).  Or,  in  a  less  intense  form,  the  shrieks  and  struggles 
or'the  groans  of  more  prolonged  suffering  are  no  less  impressive  in  their 
suggestiveness.  (b)  Not  less  characteristic  are  the  various  postures  as- 
sumed :  the  sudden  fixity  of  heart-pang;  the  retracted  head  of  meningitis ; 
the  immobile  side  of  pleurisy ;  the  crouching  attitude  of  cramp;  the  flexed 
thighs  of  peritonitis;  or  the  bent  knee  of  arthritis,  (c)  Further,  there 
are  certain  reflex  actions  that  are  associated  with  local  irritations;  thus 
the  closing  of  the  eyelid  on  irritation  of  the  conjunctiva,  the  sneeze  or 
cough  on  irritation  of  the  nasal  or  laryngeal  mucous  membrane,  the 
erection  following  irritation  of  the  urethra,  or  even  the  limp  character- 
istic of  pain  on  moving  or  resting  the  weight  of  the  body  on  an  affected 
limb.  Then  there  is  the  sudden  shrinking  of  the  whole  body,  the 
attempt  to  defend,  or  the  sudden  movement  of  the  hand  to,  the  affected 
part,  or  the  sudden  jerking  away  of  the  part  itself  if  the  act  be  pos- 
sible; these  are  true  reflexes  and  sufficiently  diagnostic  of  local  suffer- 
ing. It  scarcely  need  be  mentioned  that  in  children,  in  the  insane,  in 
persons  unable  for  many  reasons  to  communicate  their  thoughts,  the 
expression  of  pain  is  of  the  greatest  diagnostic  value  in  determining 
the  seat  of  pain,  (d)  The  associate  phenomena  of  morbid  processes 
may  serve  to  indicate  the  occurrence  of  pain  and  its  seat.  Thus  pain 
is  one  of  the  cardinal  symptoms  of  inflammation;  it  is  commonly  asso- 
ciated with  nerve-injury;  it  is  frequently  accompanied  by  local  flushing 
in  neuralgia. 

Sources  of  Error.  In  estimating  the  presence  or  absence  of  pain, 
or  its  degree,  certain  control-conditions  must  be  borne  in  mind.  Un- 
fortunately pain  is  one  of  the  most  unreliable  of  symptoms.  It  is 
necessarily  a  subjective  symptom,  with,  in  all  probability,  qualitative  as 
well  as  quantitative  variations.  The  particular  degree  in  either  respect 
is  of  importance  in  diagnosis,  and  as  only  the  roughest  means,  if  any, 
are  available  to  estimate  it  objectively,  the  physician  is  compelled  to 
rely  almost  wholly  upon  the  statements  and  appearance  of  the  patient. 
His  statement  can  err  in  two  directions  :  the  patient  can  exaggerate  his 
sufferings  or  depreciate  them.  The  tendency  to  exaggeration  is  most 
marked  in  the  nervous  temperament;  in  those  suffering  from  chronic 
disease  of  long  standing;  in  those  accustomed  to  indoor  and  mental 
labor;  in  women  and  in  the  young.  The  tendency  to  depreciation  is 
most  marked  in  the  phlegmatic  temperament;  in  those  accustomed  to 
hardship,  especially  if  of  small  intellectual  development;  in  men;  and 
in  the  aged.  Both  tendencies  are  to  be  corrected  as  nearly  as  possible 
by  observing  the  associated  symptoms  and  the  character  of  the  patient, 
and  by  skilful  questioning.  The  appearance  can  deceive  because  of 
undue'  susceptibility  to  suffering  on  the  part  of  the  patient,  or  unusual 
inhibitory  power.  There  can  be  no  question  that  painful  stimuli,  usu- 
ally easily  borne,  in  some  produce  almost  unbearable  misery.  Such 
exaggerated  sensibility  occurs  in  the  emotional,  in  the  weak  and  debili- 
tated, and  in  the  delicately  nurtured.  Mental  association  is  a  powerful 
factor;  it  is  well  known  that  soldiers,  who  in  the  heat  of  battle  disre- 
gard serious  and  necessarily  painful  wounds,  will  suffer  intensely  under 
the  probably  less  painful  offices  of  the  surgeon;  and  it  is  unfortunately 


THE  DA TA  OBTAINED  B  Y  INQ  UIB  Y.  37 

a  common  experience  that  the  surroundings  of  the  operating-room  make 
the  most  trifling  and  briefest  operations  full  of  serious  suffering. 
Habitual  use  of  opium  seems  to  increase  this  susceptibility  in  a  remark- 
able manner.  Patients  will  even  submit  to  operations  for  the  relief  of 
a  supposed  ailment  that  is  found  to  have  no  physical  basis;  and  this 
occurs  in  cases  in  which  there  is  no  reason  to  believe  that  the  pain  is 
simulated  as  an  excuse  for  the  indulgence.  Inhibition  is  a  much  more 
serious  source  of  error,  for  while  undue  attention  to  one  part  is  only 
reprehensible  when  practised  to  the  neglect  of  others,  a  patient  who 
disregards  pain  may  fail  to  direct  attention  to  the  real  seat  of  disease. 
It  is  sometimes  exercised  to  a  most  remarkable  degree.  The  stoicism 
of  the  American  Indian  under  torture  is  attested  by  many  observers; 
certain  religious  sects  among  the  Hindus  habitually  afflict  themselves  in 
the  most  ingenious  ways  ;  the  early  Christian  martyrs  rejoiced  in  mis- 
ery. It  is  common  to  find  this  disregard  of  pain  among  those  exposed 
by  occupation  to  discomforts  and  injuries,  and  the  Teutonic  and  Slavic 
races  appear  to  possess  it  in  a  higher  degree  than  the  Celtic  or  Semitic. 
Shock  either  inhibits  pain  or  diminishes  the  normal  response  to  it. 
Lastly,  and  by  no  means  to  be  neglected,  a  most  common  source  of 
error  is  undue  credulity  or  skepticism  on  the  part  of  the  physician; 
for  he  may  be  deceived  by  an  eloquent  and  persuasive  complaint,  or 
discredit  true  suffering. 

Simulated  pain  (see  Feigned  Disease)  is  to  be  recognized  by  the 
existence  of  a  motive  for  deception.  The  simulation  is  common  enough 
in  those  who  seek  damages  for  injuries,  or  in  those  who  have  a  morbid 
craving  for  sympathy  and  attention.  Its  detection  depends  upon  the 
skill  of  the  physician,  who,  by  distracting  the  attention  from  the 
part  complained  of,  observes  that  the  pain  disappears,  or,  on  the 
other  hand,  that  pain  is  admitted  in  a  part  to  which  attention  is 
directed;  moreover,  the  physician  observes  an  absence  of  adequate 
physical  alteration,  and  usually  inconsistency  in  the  symptoms,  for  the 
malingerer  is  seldom  able  to  simulate  a  correct  clinical  representation 
for  any  length  of  time.  Especially  in  the  latter  case  is  the  observa- 
tion of  the  invalid' s  surroundings  of  considerable  importance.  The  so- 
called  hysterical  mask  is  of  much  value ;  the  bitter  complaints  and  the 
placid  or  even  smiling  features  cannot  fail  to  strike  the  observer  by 
their  incongruity.  True  hysteria  is  apt  to  be  deceptive,  and  more  than 
one  humiliating  failure  is  recorded  of  even  the  most  skilful  of  our  craft. 
The  difficulty  is  increased  because  actual  physical  changes  occur,  as 
amaurosis  with  dilatation  of  the  pupil,  contracture  and  induration  about 
the  joints,  unquestionable  anaesthesias  and  palsies.  True  hysteria  is 
often  to  be  detected  only  after  prolonged  and  painstaking  study  of  the 
case;  the  careful  exclusion  of  organic  visceral  disease;  by  the  absence 
of  the  characteristic  symptoms  of  the  nervous  degenerations,  such  as 
ankle-clonus,  or  altered  electrical  reactions,  or  changes  of  the  fundus 
oculi;  and  often  by  the  impossibility  of  associating  the  sensory  lesions 
with  the  known  anatomical  distribution  of  the  nerves. 

Objective  Investigation  of  Pain.  In  order  to  estimate  accurately 
the  diagnostic  value  of  pain,    the  statement  of  the  patient  must   be 


38  GENERAL  DIAGNOSIS. 

corrected  by  his  expression,  posture,  and  manner,  and  the  apparent 
nature  of  the  disease.  Pain  is  one  of  the  cardinal  symptoms  of  inflamma- 
tion; vasomotor  and  muscular  disturbances  are  often  associated  with 
neuralgia;  any  morbid  condition  exerting  pressure  on  a  nerve-trunk,  as 
a  neoplasm,  callus,  etc.,  commonly  causes  pain.  Hence,  if  the  objective 
phenomena  of  these  disorders  are  present,  they  lend  color  to  the  com- 
plaint of  pain,  and,  if  not,  they  should  be  inquired  for.  Attempts 
have'been  made  to  estimate  the  acuteness  of  the  pain-sense  with 
scientific  accuracy,  or  at  least  to  secure  a  practical  method  for  measur- 
ing its  varying  intensity  in  different  localities  in  the  same  case.  Bjorn- 
strom,  of  Upsala,  has  contrived  a  pair  of  forceps  that  compress  a  fold 
of  skin;  the  amount  of  pressure  required  to  produce  pain,  which  can 
be  read  from  a  scale,  indicates  the  degree  of  sensibility  or  rather  resis- 
tance to  painful  impression.  Another  instrument,  Buch'  s,  accomplishes 
the  same  thing  by  direct  pressure,  and  hence  can  be  used  over  the 
superficial  nerve-trunks.  Another  method  more  generally  available 
is  the  application  of  an  induced  current  of  variable  strength;  single, 
naked-wire  electrodes  being  best  for  this  purpose.  The  common  clin- 
ical method,  by  far  the  most  inaccurate  and  only  applicable  in  cases  of 
marked  analgesia,  is  a  pin  or  needle  forced  through  a  fold  of  skin.  Xo 
method  has  yet  been  suggested  for  even  the  approximate  estimation  of 
the  acuteness  of  sensibility  to  internal  pain,  and  it  must  still  be  left  to 
the  judgment  of  the  patient. 

The  Clinical  Value  of  Pain.  The  presence  of  pain  is  recognized 
by  the  above-mentioned  circumstances.  Its  degree,  with  the  limita- 
tions indicated,  has  been  estimated.  Its  clinical  value  is  then  to  be 
considered.  From  what  has  been  said  above,  the  converse  of  many  of 
the  propositions  is  true.  By  pain  and  the  mode  of  its  expression  we 
can  judge  of  the  character,  temperament,  and  nervous  susceptibility 
and  perturbability  of  the  patient.  It  aids  us  in  the  recognition  of  hys- 
teria and  helps  to  detect  the  malingerer.  We  learn  the  patient' s  capa- 
bility  of  resistance,  and  hence,  in  a  measure,  his  strength.  'We  learn 
the  quickness  of  receptivity  in  consciousness  of  the  peripheral  irrita- 
tion, or  the  degree  of  intelligence,  or  the  amount  of  stupor.  Or,  if 
conditions  are  present  which  usually  cause  pain,  its  absence  may  show 
disease  of  the  conducting  paths  to  the  brain.  Further,  the  absence  of 
pain  under  the  above  circumstances  points  to  the  occurrence  in  the  local 
process  of  such  change  as  has  destroyed  peripheral  nerve -endings. 
Thus,  when  pain  ceases  in  dysentery  gangrene  has  ensued.  In  intes- 
tinal obstruction  its  cessation  indicates  the  same  process.  In  profound 
shock  pain  is  not  complained  of;  the  amount  of  pain,  therefore,  indi- 
cates the  degree  of  shock.  Hence,  in  peritonitis,  in  which  shock  fre- 
quently occurs,  pain  may  be  wanting  entirely.  The  abdominal  surgeons 
welcome  its  occurrence  after  an  operation,  as  it  indicates  the  absence 
of  shock. 

While  the  above  lessons,  from  the  presence  or  absence  of  pain,  are 
not  to  be  underestimated,  the  value  of  pain  to  the  physician  is  from 
the  standpoint  of  diagnosis. 

Bv  this  symptom  we  may  be  enabled  to  determine  the  location  of 


THE  DATA  OBTAINED  BY  INQUIRY.  39 

disease,  and  (1)  the  nature  of  the  causal  morbid  process.  The  location 
of  the  disease  is  determined  (a)  by  the  seat  of  the  pain  and  (6)  in  part  by 
its  character.  The  characteristics  by  which  pain  is  recognized  (see  p. 
35)  also  indicate  to  us  its  point  of  origin  in  a  general  way,  and  its 
probable  cause.  They  are  (1)  the  facial  expression,  (2)  the  posture, 
(3)  the  reflex  actions,  (4)  the  associate  phenomena.  They  need  not  be 
referred  to  again.  (See  p.  36.)  (2)  The  nature  of  the  causal  morbid 
process  is  judged  by  the  study  of  pain  from  various  standpoints.  Thus 
in  the  case  in  which  pain  is  complained  of  we  must  learn  (1)  the  mode 
of  onset,  (2)  the  duration,  (3)  the  time  of  occurrence,  (4)  the  character 
or  variety  of  the  pain,  (5)  its  seat,  (6)  its  variability  as  affected  by 
pressure,  temperature,  rest,  motion,  posture,  electricity,  drugs,  and 
climate. 

1.  Mode  of  Onset.  The  mode  of  onset  of  the  pain  is  in  the  ma- 
jority of  cases  an  indication  of  the  acuteness  of  the  morbid  process. 
a.  The  onset  may  be  sudden.  1.  In  gout  or  acute  inflammations  of 
serous  membranes,  as  pleurisy  or  peritonitis,  pain  may  occur  suddenly. 
2.  It  is  sometimes  of  sudden  occurrence  in  certain  headaches,  partic- 
ularly in  those  of  congestive  or  emotional  origin.  3.  When  pain 
occurs  suddenly  it  is  due  either  to  sudden  obstruction  of  parts  that  are 
sensitive  or  to  effort  on  the  part  of  the  structure  to  remove  a  for- 
eign body,  as  in  the  intestines,  the  gall-ducts,  the  vermiform  appendix; 
in  the  respiratory  tract,  the  nares  or  the  bronchi;  in  the  genitourinary 
tract,  the  ureters,  bladder,  or  uterus.  4.  Moreover,  sudden  pain  may 
indicate  rupture  of  the  structure  in  which  it  is  developed.  Here  we 
have  the  most  typical  sudden  pain.  Thus,  in  rupture  of  an  aneurism 
or  of  the  heart  there  is  sudden,  sharp  pain.  In  rupture  or  perforation 
of  the  stomach  or  intestines,  or  any  of  the  hollow  viscera,  this  character 
of  pain  arises.  5.  Sudden  pain  also  occurs  in  certain  neuralgias  or 
neurosal  affections.  It  is  seen  in  its  most  striking  form  in  angina  pec- 
toris, and  in  sudden  browache,  or  trigeminal  neuralgia,  b.  The  onset 
may  be  gradual.  Such  onset  indicates  that  the  process  is  one  of  slow 
development  and  not  attended  by  a  "  solution  of  continuity,"  as  from 
rupture  or  tear.  It  is  the  pain  that  usually  occurs  in  various  forms 
of  rheumatism,  in  inflammations  of  muscles  and  of  mucous  mem- 
branes, in  chronic  inflammations  of  serous  structures,  and  in  chronic 
bone  disease. 

2.  Duration.  The  duration  of  the  pain  indicates  the  acuteness  or 
chrouicity  of  the  causal  morbid  process,  a.  Pain  of  short  duration  is 
seen  in  the  affections  in  which  it  develops  suddenly  (see  Mode  of 
Onset),  in  acute  serous  inflammations,  and  in  neuralgias.  6.  Pain  of 
long  duration,  if  constant,  is  usually  due  to  organic  lesions;  if  inter- 
mittent, it  may  be  due  to  neuralgia.  Pain  that  is  continued  over  a 
long  period  of  time  excludes  the  sudden  accidents  that  were  previously 
mentioned,  unless  change  in  the  character  of  the  pain  takes  place. 
Pain  is  also  divided,  as  to  duration,  into  temporary  and  constant  pain. 
a.  Temporary  pain  indicates  an  abeyance  or  relief  of  the  morbid  pro- 
cess, while  the  constant  pain  points  to  its  continuance,  h.  Constant  pains 
are  seen  in  bone  affections,  in  inflammation  of  muscles,  in  reflex  pains 
due  to  chronic  disease  elsewhere,  as  the  backache  of  uterine  disease, 


40  GENERAL  DIAGNOSIS. 

or  the  infranranimary  neuralgias  from  the  same  cause.  Paiu  may  also 
be  intermittent,  remittent,  and  paroxysmal  or  periodic,  a.  Intermit- 
tent and  remittent  pains  are  characteristic  of  neuralgias,  or  point  to  a 
functional  origin;  they  are  recurring  because  the  cause  which  superin- 
duces them  is  again  operative.  Thus  recurring  headaches  due  to  eye- 
strain may  be  intermittent  or  remittent  in  the  sense  that  they  occur  only 
when  the  eye  is  used.  Attacks  of  such  pain  recur  over  a  long  period. 
b.  Paroxysmal  pain  is  the  form  which  occurs  when  there  is  obstruction 
of  channels,  as  the  gall-ducts  in  biliary  colic;  the  intestines,  the  uterus, 
and  the  ureters  in  the  various  forms  of  colic  to  which  they  are  liable. 
The  paroxysms  of  pain  recur  in  the  course  of  the  attacks,  c.  The  term 
periodic  is  applied  to  pains  that  occur  at  distinct  intervals.  Pain  that  is 
periodic  has  frequently  for  its  cause  malaria  in  some  form.  The  toxic 
headaches  and  nerve  headaches,  as  migraine,  are  often  periodic.  (Con- 
sult Headaches.)  Pain  that  attends  definite  states  of  exhaustion  which 
occur  periodically,  as  at  the  menstrual  period,  is  of  this  type. 

3.  The  Time  of  Occurrence.  Evidence  of  diagnostic  value  is 
derived  from  knowledge  as  to  the  time  of  the  occurrence  of  pain. 
Pains  may  occur  in  the  daytime,  or  only  during  the  night.  ]Socturnal 
pains  are  common  in  syphilis.      They  are  usually  due  to  periosteal 

.inflammation,  and  occur  after  the  patient  is  in  bed.      DiurnaL^pains 

are  usually  reflex  from  functional  disorders.     Some  pams7as*neadache 

due  to  cardiac  weakness  and  to  forms  of  anaemia,  are  present  duririgTne 

*  day,  because"13ie~~patient  is  in  the  upright  position.     They  disappear 

in  the  recumbent  position,  and  hence  are  not  present  at  night. 

The  time-relation  of  pain  to  functional  acts  is  of  importance.  Thus 
in  gastric  pain  its  relation  to  the  taking  of  food  is  to  be  ascertained. 
Pain  coming  on  before  meals  is  gastralgic  ;  occurring  after  meals,  it 
is  due  to  ulcer  or  cancer,  sometimes  to  indigestion.  So  we  inquire  of 
chest  pain,  is  it  increased  by  the  act  of  breathing  ? 

4.  Character.  Pain  may  be  sharp,  lancinating,  stabbing,  throb- 
bing; or  it  may  be  dull  in  character.  The  former  is  usually  due  to 
inflammation  of  serous  membranes,  to  colic  in  various  forms,  and  to 
forms  of  neuralgia.  Cutting  pain  is  a  sharp  form  that  occurs  in  flatu- 
lent colic.  Throbbing  pain  is  usually  associated  with  acute  inflamma- 
tion, whether  superficial  or  deep.  It  may  be  rhythmical  with  the  pul- 
sations of  the  heart.  Dull  pain  is  due  to  slow  chronic  inflammation 
in  the  bones  and  in  the  viscera;  it  is  the  pain  of  myalgia  and  of  fatigue 
in  the  muscles.  It  may  be  of  an  aching  character.  But  aching  pains 
may  also  be  general;  they  are  found  among  the  prodromata  of  the  acute 
diseases,  attend  and  follow  a  chill,  and  occur  in  most  characteristic 
form  in  influenza  and  dengue.  Pressing  pain  is  complained  of  when 
it  attends  an  attempt  to  remove  material  from  the  viscera,  as  the  pas- 
sage of  water  when  the  bladder  is  inflamed;  the  passage  of  faeces  in 
dysentery.  The  term  tenesmus  is  applied  to  it,  so  that  we  have  vesical 
tenesmus  and  rectal  tenesmus.  The  passage  of  clots  or  other  material 
from  the  uterus  is  attended  by  pain  with  pressure  or  "  bearing-down," 
as  it  is  termed. 

Finally,  the  character  of  pain  is  often  an  indication  of  the  nature 
of  the  disease  as  well  as  of  the  tissue  affected  :  1.   Thus,  the  bone  and 


THE  DATA  OBTAINED  BY  INQUIRY.  41 

periosteal  pains  are  boring  and  constant.  2.  In  muscular  affections 
there  is  soreness  or  aching.  3.  In  the  serous  membranes  the  pain  is 
sharp  and  stabbing.  4.  In  the  mucous  membranes,  smarting  and  burn- 
ing, or,  perhaps,  dull  and  sore.  5.  In  the  skin,  burning  or  itching. 
6.  In  the  viscera,  dull  and  usually  steady;  although  in  malignant 
disease  of  the  various  organs  it  may  be  sharp  and  paroxysmal.  7. 
Aching,  burning,  and  throbbing,  in  the  nerve-trunk  and  its  distribu- 
tion, with  tenderness,  commonly  indicate  neuritis.  (See  "  pain 
crises,"  p.  43.) 

5.  Location.  This  is,  in  general,  an  indication  of  the  location  of 
the  disease.  It  may  be  accepted  as  an  almost  universal  rule  that  pain 
due  to  a  local  process  is  limited  to  the  immediate  or  associated  nerve- 
supply  of  the  diseased  region.  This  holds  true  even  Avhen  the  referred 
pains — that  is,  those  felt  in  the  associated  nerve-supply — are  as  far  dis- 
tant from  the  site  of  the  morbid  process  as  the  knee  pain  of  coxitis, 
the  shoulder  pain  of  hepatic  disease,  or  the  ear  and  temporal  pain  of 
lingual  carcinoma. 

It  may  be  of  questionable  advantage  in  some  cases  that  the  localiza- 
tion of  pain  generally  indicates  the  situation  of  the  morbid  process. 
Too  often  an  apparently  adequate  explanation  of  the  symptoms  may 
thus  be  found,  whilst  other  pathological  changes  may  be  overlooked. 
But,  on  the  other  hand,  the  condition  to  which  attention  has  been  called 
by  the  pain  might,  on  account  of  its  obscurity  or  unusual  location, 
altogether  escape  observation. 

In  the  first  place,  we  determine  whether  pain  is  general  or  local.  1. 
General  pains  are  due  either  to  central  or  to  peripheral  disturbance  of 
the  nervous  system  by  a  poison  circulating  in  the  blood.  This  may 
be  the  poison  of  fevers,  or  may  be  a  rheumatic  or  gouty  poison.  It 
is  seen  in  the  common  affection  known  as  "  cold,"  when  the  pains  are 
probably  myalgic.  In  syphilis,  malaria,  lead-poisoning,  and  toxaemias 
generally,  there  are  general  pain,  soreness,  and  fatigue.  General  pains 
are  not  confined  to  the  muscles,  but  are  also  seated  in  the  fibrous  struc- 
tures and  bones.  In  their  more  severe  forms  such  pains  occur  in  den- 
gue, and  are  known  as  ' '  break-bone. ' ' 

2.  Local  pains  may  be  (a)  superficial  or  deep-seated;  (5)  limited  to 
a  small  area  or  radiating  in  various  directions. 

a.  Superficial  pains  are  due  to  involvement  of  the  superficial  nerves 
distributed  to  the  skin  or  to  the  muscles  directly  underneath,  or  to  the 
structures  in  close  relation  to  the  skin,  as  the  peritoneum,  the  pleura, 
or  the  pericardium.  Deep-seated  pains,  when  in  the  extremities,  are 
due  to  bone  disease;  when  in  the  abdomen,  to  disease  of  the  viscera, 
particularly  inflammatory  affections;  when  in  the  chest,  to  disease  of 
the  aorta  and  mediastinum.  The  diagnostic  value  of  these  forms  of 
pain  can  readily  be  appreciated.  Thus,  when  pain  is  complained  of 
in  the  abdomen,  if  superficial,  it  is  due  to  the  nerves  and  the  muscle 
or  to  the  peritoneum.  If  deep-seated,  it  may  be  due  to  inflammation 
along  the  vertebral  column,  to  cancer  or  ulcer  of  the  stomach,  to  aneu- 
rism, to  disease  of  the  pancreas  or  of  the  liver.  If  in  the  lower  por- 
tion of  the  abdomen,  it  is  due  to  pelvic  or  renal  disease.  (See  Abdo^- 
men.)     In  the  same  manner,  in  the  chest  the  superficial  pains  are  due 


42  GENERAL  DIAGNOSIS. 

to  affections  of  the  walls  of  the  thorax,  or  of  the  serous  coverings  of 
the  lung  or  heart.     The  causes  of  deep  pain  have  been  mentioned. 

6.  The  area.  In  studying  the  localization  of  pain  we  inquire  whether 
it  is  circumscribed,  diffused,  or  radiating.  Circumscribed  pain  is  always 
due  to  a  small  area  of  disease,  or  is  reflex.  Thus,  in  ulcer  of  the 
stomach  the  pain  is  usually  circumscribed  to  a  small  area  in  the  epigas- 
trium ;  in  inflammation  of  the  appendix,  to  the  region  of  that  structure. 
Diffused  pain  indicates  involvement  of  a  large  area  with  less  intensity 
of  process  than  when  circumscribed.  Pains  that  are  radiating  are 
usually  felt  in  the  area  of  the  nerve-distribution  related  to  the 
point  of  their  origin.  We  learn  much  from  the  study  of  this  distri- 
bution :  the  pain  of  cancer  of  the  anterior  portion  of  the  tongue  may 
be  chiefly  complained  of  in  the  ear;  the  pain  of  disease  of  the  hip,  at 
the  knee-joint;  of  the  liver,  at  the  shoulder.  The  pain  of  angina 
radiates  down  the  arms;  of  renal  disease,  to  the  head  of  the  penis  or  to 
the  testicles.  The  pain  of  diaphragmatic  pleurisy  is  referred  to  the  front 
of  the  abdomen  above  the  umbilicus.  Peripheral  pains.  Radiating 
pains,  however,  are  chiefly  due  to  disease  in  the  course  of  the  nerve, 
the  pain  being  referred  to  its  trunk  and  terminal  distribution.  Pain 
from  disease  or  pressure  upon  the  nerves  at  their  exit  from  the  spinal 
canal  is  felt  at  the  periphery  of  the  nerves  at  the  centre  of  the  abdo- 
men, and  not  at  the  point  of  exit.  Pain  over  the  abdomen  is  frequently 
an  indication  of  disease  of  the  vertebrae,  propagated  by  the  sixth  or 
seventh  dorsal  nerve.  Pain  between  the  shoulders  is  often  due  to 
aneurism  which  presses  upon  the  vertebrse.      (See  Pain  in  the  Heart.) 

Hilton  lays  down  the  rule  that  pain  in  any  part,  in  the  absence  of 
local  inflammation,  is  due  to  exalted  sensitiveness  of  the  nerves  of  that 
part,  and  depends  upon  a  cause  remote  from  the  painful  area.  The 
term  sympathetic  is  applied  to  this  group  of  pains.  Further,  Hilton 
remarks  that  pain  on  the  surface  of  the  body  must  be  expressed  by 
the  nerve  which  resides  there,  and,  hence,  the  cause  of  the  pain  must 
be  situated  between  the  peripheral  termination  and  its  central  origin. 
This  applies  particularly  to  the  pains  which  arise  from  disease  of  the 
vertebrse.  To  the  same  class  belongs  the  pain  on  the  inner  side  of  the 
knee  in  hip  disease;  at  the  extremity  of  the  urethra,  in  disease 
o?  the  bladder;  in  the  testes  and  thigh,  in  renal  calculus;  and  at 
the  tip  of  the  shoulder,  in  affections  of  the  liver.  For  the  same  reason 
pain  over  different  areas  of  the  scalp  should  be  investigated,  for  a 
localized  pain  is  often  due  to  disease  of  the  fifth  nerve  in  some  part 
of  its  course.  In  a  similar  manner  pain  in  the  legs  is  frequently  due 
to  cancer  of  the  rectum  or  bladder.  In  ulcer  of  the  rectum,  pain, 
cramps  in  the  legs,  numbness,  and  even  loss  of  muscular  power  are 
sometimes  confined  to  the  left  side.  The  same  lesion  causes  pain  in 
the  lumbar  region,  as  well  as  in  the  limbs.  Hilton  describes  a  case 
in  which  pain  over  the  sciatic  nerve,  over  the  left  hip  and  loin,  and 
over  the  right  leg,  was  due  to  a  small  ulcer  in  the  anus,  the  curing 
of  which  relieved  the  pain.  Of  somewhat  different  class  is  the  pain 
in  the  phrenic  nerve,  in  the  neck,  due  to  pericarditis  or  to  diaphrag- 
matic pleurisy.  As  a  corollary  to  this,  in  the  investigation  of  the 
cause  of  pain,  the  nerve,  its  anastomoses,  and  the  organs  supplied  by 


THE  DA  TA  OB TAIXED  B  Y  IXQ  UIR  Y.  43 

it  should  be  investigated.  Bilateral,  symmetrical,  and  superficial  pains 
indicate  a  central  or  bilateral  cause;  while,  on  the  other  hand,  unilateral 
pain  implies  a  seat  of  origin  which  is  one-sided. 

Peripheral  Pain  of  Central  Origin.  In  addition  to  peripheral  pains 
of  such  origin,  we  have  referred  to  pains  of  the  extremities  or 
trunk  due  to  central  disease.  In  meningitis  and  other  general  organic 
affections  of  the  brain  and  cord  peripheral  pains  are  most  common, 
and  may  be  the  earliest  and  most  striking  symptoms.  Indeed,  it  is 
very  common  to  find  patients  with  spinal  disease  who  have  been  treated 
for  a  long  time  for  what  was  supposed  to  be  rheumatism.  The  pains  of 
central  origin  in  the  joints  may  be  constant  or  they  may  be  paroxysmal 
and  lancinating  when  the  disease  is  chronic.  (See  Character,  p.  40.) 
The  paroxysms  of  pain  may  be  most  excruciating,  and  sometimes  cause 
collapse.  They  are  known  as  painful  crises.  Pain  may  be  complained 
of  in  various  viscera,  as  well  as  in  the  joints.  Sudden,  intense  pain, 
with  functional  disturbances  of  the  affected  viscera,  occurs  indepen- 
dently of  any  lesion  of  the  part  or  of  any  apparent  exciting  cause.  One 
class  of  the  attacks  is  known  as  gastric  crises.  The  pain  is  in  the  epi- 
gastrium, and  is  associated  with  vomiting.  In  another  class  laryngeal 
crises  occur,  with  pain  in  the  larynx  and  violent  spasmodic  cough,  with 
dyspnoea,  The  pain  extends  over  the  shoulders.  Or  we  may  have 
rectal  crises,  Avith  sensation  of  burning  in  that  situation ;  urinary  crises, 
simulating  renal  colic,  and  genital  crises.  Pains,  in  crises,  also  occur 
in  the  muscles.  Crises  occur  chiefly,  if  not  entirely,  in  locomotor 
ataxia.  They  are  distinguished  from  pain  due  to  other  causes  by 
their  sudden  onset,  their  extreme  severity,  the  absence  of  organic  dis- 
ease or  local  cause  in  the  affected  viscera,  the  sudden  termination,  the 
normal  condition  between  the  attacks. 

Pain  in  the  joints  and  in  the  periphery  of  the  extremities  is  of  fre- 
quent occurrence  in  neuritis;  inflammation  of  the  sciatic  nerve  may 
cause  pain  in  the  foot. 

6.  Pain  Modified  by  Pressure,  Movement,  Rest.  We  also 
study  pain  under  the  influence  of  pressure,  movement,  temperature, 
rest,  etc.  Pain  that  is  modified  by  pressure  is  generally  superficial. 
It  is  usually  of  an  inflammatory  origin.  The  variety  of  the  pressure 
gives  some  clue  to  the  nature  of  the  pain.  If  the  pain  is  increased  by 
pressure  of  the  finger-tips,  it  is  due  to  ulcer  or  inflammation,  when 
internal,  and  to  inflammation  if  external.  Although  of  visceral  origin, 
gastralgia  and  colicky  pains  in  the  intestine,  which  may  be  neurotic, 
are  relieved  by  pressure,  particularly  if  the  whole  hand  is  applied. 
Pain  from  the  dislocation  of  an  organ,  as  a  movable  kidney  or  displaced 
uterus,  or  from  dependent  viscera,  may  be  relieved  by  judicious  pres- 
sure in  the  proper  direction  so  as  to  relieve  the  displacement.  The 
pain  that  arises  from  affections  of  the  nerve-trunks  can  be  distinctly 
localized  by  pressure  in  the  course  of  the  nerve-trunk,  and  particularly 
at  the  points  where  the  cutaneous  filaments  of  the  nerves  come  through 
the  fascia,  These  points  in  the  thorax  arc  along  the  vertebra]  column, 
in  the  axillary  region,  and  anteriorly  about  the  parasternal  line.  We 
distinguish  neuralgias  from  myalgias  by  the  presence  of  these  tender 
points.      Pain  due  to  bone  disease  can  frequently  be  distinguished  in 


44  GENERAL  DIAGNOSIS. 

this  way.  By  pressure  or  weight  upon  the  head  or  shoulders  we  may 
ascertain  if  pain  is  due  to  vertebral  disease.  ^_i__z^ 

Pain  increased  by  movement  points  to  an  affection  of  the  bone,  muscle, 
joint,  or  nerve  in  the  part  moved;  groups  of  muscles  may  be  isolated 
for  the  tests.  Some  few  pains  are  relieved  by  movement  of  the  body, 
only  because  the  mind  is  diverted  in  this  act.  Pain,  when  increased  by 
movement  and  superficial,  is  due  to  neuritis,  myalgia,  or  rheumatism. 

Almost  all  pains  are  modified  by  rest.  Its  influence  has  but  little 
diagnostic  significance.  In  some  cases  of  doubt  as  to  the  nature  of  a 
visceral  pain,  functional  rest  of  the  organ,  by  which  relief  is  obtained, 
may  aid  in  determining  its  locality.  Thus,  rest  to  the  eye  may  relieve 
a  headache,  the  nature  of  which  was  obscure  until  this  respite  was 
secured.  Pain  modified  by  temperature  (cold  or  heat  applied  to  the 
spine,  ice  or  hot  water  in  a  sponge)  and  by  electricity,  usually  gives 
information  as  to  the  seat  of  the  disease  in  the  spinal  column,  of  which 
the  pain  is  the  external  expression.  Pain  modified  by  climate  is  rheu- 
matic or  neuralgic;  if  modified  by  weather  or  season,  it  is  due  to  neu- 
ralgia or  neuritis,  whether  of  gouty  or  traumatic  origin.  (See  papers 
by  Weir  Mitchell.) 

Resume.  Notwithstanding  clinical  investigation  we  may  not  be 
able  from  the  character  and  locality  to  determine  the  real  cause  of  the 
pain.  In  general  it  may  be  borne  in  mind  that  pains  are  due  (1)  to 
disease  of  the  central  nervous  system  or  the  nerve  trunks;  (2)  to 
inflammations;  (3)  to  intoxications,  as  from  malaria,  lead,  and  other 
forms  of  toxaemia;  (4)  to  pressure  on  the  nerve-trunks;  (5)  to  reflex 
influences.  If  in  doubt,  therefore,  the  general  symptoms  and  condi- 
tion of  the  patient  must  be  ascertained  in  order  to  determine  the  causal 
origin,  and  hence  the  true  nature  of  the  pain.  In  all  cases  of  pain 
the  controlling  motive  in  diagnosis  should  be  to  determine  the  general 
condition  of  the  patient  and  find  the  cause  of  the  pain. 

Reference  must  be  made  to  the  curious  change  that  takes  place  in 
persons  with  chronic  morphine-intoxication.  Such  persons  are  very  apt 
to  have  functional  pain.  This  form  of  pain  is  usually  paroxysmal 
and  severe,  and  may  simulate  organic  pains.  The  most  common 
clinical  form  seen  is  gastralgia.  The  subjects  of  locomotor  ataxia 
suffer  from  pain  on  account  of  which  they  have  to  take  enor- 
mous doses  of  morphine.  This  habit  is  soon  acquired,  but  notwith- 
standing the  large  dose  of  the  drug  paroxysmal  pain  continues;  in  its 
severity  it  simulates  the  crises  of  the  primary  disease.  It  becomes  a 
very  difficult  matter,  and  is  often  impossible,  to  decide  whether  the 
pain  is  due  to  the  morphine-habit  or  to  the  primary  affection. 

Pain  in  Special  Reg-ions.  (For  the  head  pain,  see  Nervous  Dis- 
eases; for  pain  in  the  thorax  and  abdomen,  see  the  respective  sections.) 

Pain  in  the  Extremities.  We  have  referred  to  pain  in  the  extrem- 
ities which  may  be  due  to  disease  of  the  spinal  cord,  and  to  pain  of 
neurotic  or  toxsemic  origin.  When  not  due  to  local  traumatic,  rheu- 
matic, or  gouty  inflammations,  pain  in  the  extremities,  unilateral  or 
bilateral,  is  usually  due  to  neuritis  of  some  form.  It  is  recognized  by 
tenderness  in  the  course  of  the  sciatic  nerve  or  at  its  exit  from  the 


THE  DA  TA  OB  TAINED  B  Y  INQ  UIB  Y.  45 

pelvis,  and  by  increase  in  the  pain  when  the  limb  is  extended  by 
forced  movement.  One  of  the  many  branches  of  the  sciatic  may  be 
affected,  exhibiting  tenderness  in  its  course.  Such  neuritis  is  usu- 
ally traumatic  (cold),  alcoholic,  rheumatic,  gouty,  or  syphilitic;  the 
exact  cause  in  each  case  must  be  ascertained  by  the  associate  phe- 
nomena and  by  the  exclusion  of  other  causes.  For  instance,  we 
distinguish  the  gouty  or  rheumatic  state  by  (1)  the  history  of 
previous  attacks  of  pain  or  rheumatism  in  other  situations;  (2)  the 
family  history  of  rheumatism;  (3)  the  history  of  the  exposure  which 
induced  the  attack;  (4)  the  character  of  the  pains;  (5)  the  occurrence 
of  pain  or  rheumatic  manifestations  in  other  tissues,  as  myalgia  or  pain 
in  the  fascia;  (6)  the  occurrence  of  symptoms  of  lithaemia  (which  see); 
and  (7)  the  character  of  the  urine. 

Bilateral  pains  in  the  extremities  are  often  of  central  origin. 

Fixed  pains  in  an  extremity,  in  contradistinction  to  the  mobile  pains 
of  neuritis,  are  usually  situated  in  the  fasciae  or  muscles,  or  in  the  bony 
structure  of  the  part.  They  may  be  the  result  of  strain  or  injury,  a 
history  of  which  must  be  carefully  inquired  for.  The  latter  may  be 
only  the  exciting  cause,  if  it  occurs  in  a  person  of  rheumatic  diathesis, 
the  fixed  pain  at  the  situation  of  the  injury  being  due  to  the  general 
rheumatic  state.  Fixed  traumatic  pains  are  usually  accompanied  by 
tenderness  on  pressure,  and  aggravated  by  movement  both  active  and 
passive,  the  tenderness  on  pressure  not  necessarily  being  in  the  nerve- 
trunk.  The  special  pains  about  the  foot  which  we  are  called  upon  to 
treat,  which  have  their  origin  in  causes  independent  of  the  nerves, 
being  of  a  rheumatic  or  gouty  diathesis,  are : 

1.  Pain  in  the  articulations  due  to  flat-foot.  This  may  be  in  the 
tarsus  or  at  the  metatarsal  articulations.  It  is  a  common  cause  of  pain 
in  the  extremities  and  may  be  unilateral  or  bilateral.  Flat-foot  from 
breaking  of  the  arch  can  readily  be  recognized;  pressure  on  the  sole 
of  the  foot  may  increase  the  pain. 

2.  Pain  in  the  heel.  This  is  often  of  gouty  origin,  and  is  a  persist- 
ent source  of  complaint  in  many  instances. 

3.  Pain  in  the  interosseous  spaces  between  distal  ends  of  the  third  and 
fourth  metatarsal  bones  (Morton's  painful  affection  of  the  foot).  It 
occurs  in  people  who  are  on  the  feet  a  great  deal,  is  relieved  by  a  night' s 
rest,  increases  as  the  day  goes  on,  and  is  increased  by  pressure  or  by 
wearing  a  tight  shoe.  It  is  worse  in  wet  and  cold  weather.  Localized 
pressure  at  the  point  on  the  sole  indicated  above  causes  extreme  pain. 

We  cannot  leave  the  extremities  without  a  Avord  regarding  pains 
in  the  extremities  of  distinctly  central  origin — the  forerunners  of 
hemorrhage  into  the  brain.  Mitchell  has  called  attention  to  these 
pains.  They  occur  suddenly  without  evidence  of  local  disease;  they 
are  located  in  one  of  the  extremities,  usually  the  leg,  are  excruciat- 
ing, and  not  influenced  by  position,  local  applications  or  pressure.  In 
a  patient  with  hard  arteries  and  high  pulse-tension  they  should  be  looked 
upon  with  suspicion. 

Pains  of  the  Thorax.  Painful  diseases  of  the  muscles  and  of  the 
viscera  arc  excluded  from  consideration;  pains  of  reflex  origin  will  be 


46  GENERAL  DIAGNOSIS. 

referred  to.  They  are  usually  seated  in  the  shoulder  or  the  back,  and 
are  due  to  liver  or  gastric  disease.  The  pain  of  liver  disease  is  referred 
to  the  right  shoulder  ;  of  ulcer  of  the  stomach,  to  the  interscapular 
region  and  the  lumbar  region,  or  to  the  top  of  the  shoulder,  as  in  a 
case  observed  by  Wood.  Pain  behind  the  sternum  is  a  reflex  neurosis 
from  gastric  disorder.  It  may  occur  in  bronchitis.  It  may  also  be 
due  to  cancer  of  the  mediastinum,  to  aneurism,  or  angina.  Pain  in 
the  sternum  or  ribs  is  syphilitic  or  due  to  periostitis  or  necrosis  follow- 
ing typhoid  fever,  rarely  to  cancer.  Chronic  fibrous  inflammation  of 
one  or  more  of  the  attachments  of  the  muscles  is  of  common  occurrence. 
The  pain  lasts  for  years.  It  is  persistent,  sometimes  associated  with 
stiffness;  it  is  increased  by  movement, and  there  may  be  extreme  aching 
pains  in  the  parts.  The  pain  of  vertebral  caries  transmitted  along 
the  course  of  the  nerve  has  been  referred  to. 

Girdle-pain.  This  is  a  peculiar  pain  or  sensation  in  the  trunk  due 
to  disease  of  the  spinal  cord.  It  is  described  as  the  sensation  of  a 
band  drawn  tightly  around  the  body.  It  varies  from  a  simple  drawing 
sensation  to  extreme  pain  which  encircles  the  trunk.  It  is  situated 
above  the  level  of  the  umbilicus.  In  milder  forms  it  is  due  to  chronic 
myelitis  or  spinal  sclerosis;  in  severe  forms  to  inflammation  of  the  nerve- 
roots,  or  to  cancerous,  syphilitic,  or  tubercular  disease  of  the  meninges. 

Pain  in  the  Spine.  Pain  in  the  spine  is  due  less  frequently 
to  organic  disease  of  the  cord  than  to  acute  or  chronic  inflamma- 
tion of  the  meninges,  to  disease  of  the  bones  of  the  vertebral  column, 
or  to  curvature  of  various  forms  from  muscle-weakness.  Rha- 
chialgia  and  tenderness  in  the  course  of  the  spine  occur  after  con- 
cussion. In  organic  disease  of  the  cord  pain  may  be  referred  to 
the  loins,  the  sacrum,  or  to  the  parts  about  the  spine,  but  not  to  the 
spinal  column  itself.  In  the  same  disease  of  the  cord  we  may  have 
also  the  eccentric  or  radiating  pains  of  which  mention  has  been  pre- 
viously made,  due  to  irritation  of  posterior  nerve-roots.  They  may  be 
dull,  resembling  those  of  rheumatism.  In  acute  cases  the  pains  are 
accompanied  by  febrile  symptoms  which  may  simulate  rheumatism, 
especially  when  the  other  spinal  symptoms  are  in  abeyance.  In  chronic 
cases  these  peripheral  spinal  pains  are  influenced  by  the  weather,  and 
this  likewise  makes  it  difficult  to  distinguish  them  from  rheumatism. 
Eheumatic  pains  in  the  limbs  occurring  particularly  after  middle  life, 
independent  of  actual  joint-changes,  should  lead  to  examination  for  loss 
of  power  of  walking  properly,  ataxia,  and  alterations  in  reflex  action, 
by  which  their  true  origin  may  be  recognized.  In  locomotor  ataxia 
sharp  and  darting  pains  occur,  "  pain  crises,"  and  girdle  sensations. 

Fixed  localized  pain  at  some  point  in  the  vertebrae  when  not  due  to 
other  conditions  points  to  local  caries,  or  may  be  of  syphilitic  or  tuber- 
cular origin,  or  due  to  pressure,  as  by  an  aneurism. 

Pain  clue  to  vertebral  disease  i*  both  local  and  radiating,  it  is  in- 
creased by  pressure  directly  on  the  spinal  column  (on  the  head),  by 
heat  or  cold,  or  by  electricity  applied  over  the  part.  It  is  relieved  by 
removing  the  pressure  of  the  weight  above,  as  by  raising  the  head  or 


THE  DATA  OBTAINED  BY  INQUIRY.  47 

shoulders.  It  is  increased  by  pressure  or  a  jar  on  the  head.  It  is 
relieved  by  the  absolutely  recumbent  posture.  The  movements  (flex- 
ibility) of  the  spine  are  interfered  with;  there  is  local  spasm  of  mus- 
cles; there  may  be  deformity.  When  the  patient  is  placed  upon  a  flat 
surface  the  normal  lumbar  arch  is  changed.  The  pain  of  curvature 
from  muscular  weakness  extends  along  nerves,  is  afebrile,  without  the 
si <ms  of  organic  disease  above  mentioned,  but  with  muscle-weakness,  and 
general  signs  of  debility.  Pain  due  to  meningeal  disease  is  local  and 
radiating.  It  is  associated  with  muscular  spasm  and  stiffness  of  the 
spinal  column. 

Pain  in  the  Side.  Pain  in  the  left  side — the  so-called  infra-mam- 
mary pain — is  one  of  the  most  frequent  complaints  heard  by  the  prac- 
titioner. By  discussion  of  it  we  can  show  how  pain,  wherever  situated, 
must  be  investigated  as  a  symptom,  in  order  to  determine  the  tissue 
affected  and  the  nature  of  the  disease.  The  tests  used  in  the  study  of 
nerve-affections  (q.  v.)  are  not  given.  It  may  be  due  to  many  causes, 
to  exclude  any  one  of  which  inquiry  as  to  the  mode  of  onset,  duration, 
and  character  of  the  pain  must  be  made.  The  structures  underneath 
and  about  the  seat  of  pain  must  be  examined.  1.  The  skin  :  to  exclude 
any  swelling  or  tumor  or  herpes  zoster,  and  to  determine  the  tender  nerve- 
points.  2.  The  muscle :  to  exclude  myalgia  or  pleurodynia.  Exam- 
ine for  tenderness;  note  the  effect  of  movement;  does  full  breathing 
increase  the  pain  ?  Palpate  with  the  fingers  and  with  the  whole  hand. 
Negative  results  exclude  any  muscular  affection.  3.  The  nerves,  (a) 
Tender  points;  (6-)  herpes;  (c)  the  vasomotor  appearances.  4.  The 
pleura.  Auscultate  for  fricton,  if  pleuritis.  Inquire  for  cough.  Note 
the  character  and  effect  of  breathing.  5.  The  pericardium.  Note 
friction  of  pericarditis  or  thrill  by  palpation.  Is  the  heart  disturbed 
in  function  ?  6.  The  heart.  It  is  rare  that  disease  of  this  organ  causes 
pain,  although  it  may  be  present  in  dilatation.  Is  it  affected  in  a  reflex 
manner,  causing  palpitation  or  irregularity  ?  Look  for  distant  disease. 
7.  The  stomach.  A  dilated  stomach  may  cause  pain  by  pressure  up- 
ward, and  so  may  gastric  disorder  acting  in  a  reflex  manner.1  8.  The 
spine.  Determine  if  it  is  diseased  or  if  there  is  pressure  by  an  aneurism. 
9.  Examine  the  blood,  for  anaemia.  10.  Toxcemia.  Inquire  for  its 
presence;  particularly  malaria,  rheumatism,  lead,  etc.  If  a  local  cause 
is  not  ascertained,  look  for  a  central  or  reflex  disorder.  The  above  course 
must  be  pursued  in  investigating  pain  in  the  side,  and  should  be  pur- 
sued in  all  cases  of  pain. 

Although  any  one  of  the  above  conditions  may  cause  pain  in  the  side, 
it  is  usually — 1,  a  reflex  pain  from  gastric  disorder;  2,  pain  from  neu- 

1  Shoulder-tip  pain,  due  to  anastomosis  of  phrenic  nerve  with  3d  and  4th  cervical  and  to  parts 
of  liver  and  round  ligament  (Hilton) ;  or  of  phrenic  nerve  and  subclavius  (Rolleston) ;  or  of  vagus 
with  spinal  accessory,  which  communicates  with  3d  and  4th  cervical.  The  v.  and  s.  a.  are  sensitive 
to  pressure.    (Embleton.) 

Infra-mammary  pain  (6th,  7th,  and  8th  intercostal  spaces).  The  aorta  at  left  side,  3d  dorsal  verte- 
bra, is  in  relation  with  the  4th,  5th,  and  Gth  intercostal  nerves  through  the  sympathetic  ganglia, 
through  which  also  the  heart  sympathetics  are  in  anastomosis.  The  4th,  5th,  and  Gth  intercostal 
nerves  supply  cutaneous  branches  to  the  6th,  7th,  and  8th  intercostal  spaces.  The  inframainmary 
pain  is  a  reflex  neuralgia  expressive  of  some  heart-distress.  The  latter  is  brought  about  by  ex- 
haustion of  the  medullary  and  vasomotor  centres,  from  worry  or  overwork,  or  from  long-continued 
irritation  of  the  uterine  nerves.  In  leucorrhcea  this  pain  is  most  common.  (Jacobson  ;  Hilton  on 
"  Rest  and  Pain.") 


48  GENERAL  DIAGNOSIS. 

ritis;  3,  a  true  neuralgia,  froni  anseuiia;  4,  a  neuralgia  from  heart- 
fatigue.      (Hilton. ) 

It  is  to  be  observed  that  every  local  tissue  must  be  examined,  and 
questions  asked  as  to  the  various  attributes  of  the  pain. 

Pain  in  the  Loins.  When  acute,  without  fever,  it  may  be  due  to 
lumbago,  to  a  sudden  uterine  retroversion,  to  a  suddenly  moved  kidney, 
or  to  calculus  of  the  kidney;  with  fever,  acute  Bright' s  disease,  small- 
pox, muscular  rheumatism,  tonsillitis,  influenza,  or  spinal  meningitis 
must  be  looked  for. 

Chronic  Pain  in  the  Back  ;  Backache.  This  may  be  due  to 
many  causes.  The  cause  varies  with  the  seat  of  the  pain.  When  it 
is  in  the  region  of  the  kidneys,  they  should  be  examined.  Organic 
disease  (Bright' s)  may  be  associated  with  backache;  more  frequently 
pain,  if  in  one  kidney,  is  due  to  a  calculus  or  to  accumulation  of 
uric-acid  gravel.  It  may  be  constant  in  moved  or  movable  kidney. 
When  low  down,  just  above  or  over  the  sacrum,  it  is  due  to  disturbance 
of  the  pelvic  viscera.  The  uterus,  the  rectum  (impacted,  cancerous) 
must  be  examined. 

Otherwise  we  may  have — (a)  Pain  due  to  affections  of  the  muscles. 
1.  Myalgia  of  rheumatic  origin.  Increased  by  movement,  by  damp- 
ness, by  pressure.  Often  relieved  by  warmth,  by  the  recumbent  pos- 
ture or  rest.  It  is  associated  with  symptoms  of  lithsemia  and  with  the 
passage  of  red  sand  in  the  urine.  When  the  fascia  or  the  ligaments 
of  the  vertebrae  are  affected,  the  upright  position  and  pressure  in  small 
areas  increase  the  pain;  other  muscles  may  be  affected  alternately. 
%  Myalgia  from  sprain.  A  history  of  injury  is  obtained.  Usually 
one  side  is  larger  than  the  other.  Tenderness  is  present  and  move- 
ment increases  the  pain.  There  may  be  increased  swelling,  vasomotor 
disturbance,-  or  ecchymoses.  A  neurosis  of  the  so-called  spinal  or 
traumatic  type  (hysteria)  attends  the  pain.  3.  Myalgia  from  fatigue. 
Not  only  acute  fatigue  after  exertion,  but  chronic  muscle-tire  (and 
nerve-tire).  The  pain  is  increased  on  exertion,  after  mental,  physical, 
or  emotional  effort.  The  muscles  are  flabby;  the  vertebral  column 
is  not  supported.  The  patient  lounges  or  supports  the  back.  De- 
formities are  observed.  Neurasthenia,  anaemia,  and  local  exhaustive 
disease  (uterine,  gastro-intestinal,  etc.)  are  present. 

(b)  Pain  due  to  affections  of  the  nerves.  Nerve-pain  is  recognized 
by  the  tender  points;  by  vasomotor  phenomena. 

(c)  Pain  due  to  disease  of  the  spine,  the  membranes,  or  the  cord. 
(See  above.) 


CHAPTER  III. 

THE  DATA  OBTAINED  BY  OBSERVATION. 

The  objective  symptoms  correspond  to  phenomena  in  nature.  Method  of  procedure  ; 
method  of  the  observer.  Inspection,  palpation,  percussion.  The  instruments 
required.  Examination  of  the  exterior.  General  examination.  The  first-sight 
impression.  The  temperament  and  constitution.  Apparent  age.  Effects  of 
habits  and  occupation.  The  attitude  and  gait.  General  form  and  nutrition. 
Changes  in  size  and  weight.  From  the  amount  of  adipose  tissue — obesity — 
emaciation.  Changes  in  the  skeleton.  Enlargement — acromegaly — osteitis 
deformans  —  pulmonary  osteo-arthropathy.  Diminution — rhachitis — osteoma- 
lacia. The  exterior  in  general.  The  skin.  The  color — redness — pallor — 
jaundice — cyanosis  —  the  bronzed  skin — Addison's  disease — chloasma  —  tinea 
versicolor — vagabond's  disease — argyria — freckles.  The  nutrition.  Moisture 
andfdryness — hyperidrosis — anhidrosis.  Scars.  Hemorrhages — mode  of  recog- 
nition— cause — significance.  Eruptions — their  clinical  significance — nature  of 
the  lesion — distribution — associate  morbid  phenomena — general  symptoms. 
Table  of  skin  diseases.  Erythema — herpes — erythema  nodosum — urticaria — 
medicinal  rashes — erythema  of  infectious  diseases — roseola — miliaria  or  suda- 
niina.  General  diagnosis.  Enlargements  of  the  subcutaneous  connective  tissue. 
GCdema — causes — mode  of  recognition — situation — feet,  face,  arms,  and  head — 
cedema  of  trichinosis — angio-neurotic  cedema.  Myxcedema.  Connective-tissue 
dystrophies.  Scleroderma.  Sarcomata — cysticercus  cellulosse — brawny  indura- 
tion. Subcutaneous  nodules.  The  temperature.  Fever.  Causes  of  body -heat 
and  fever  —  mode  of  determination  —  physiological  variations  —  pathological 
variations — the  types  of  fever — the  course  of  the  fever — initial  stage,  fastigium. 
defervescence — crisis — lysis — the  daily  range — recrudescence.  The  symptoms 
of  fever.  Subnormal  temperature.  The  diagnostic  significance  of  fever.  The 
general  musculature.  General  abnormal  vital  conditions.  Fits  or  seizures — 
coma — collapse — shock.  Local  examination  of  the  exterior.  The  face — the 
facial  expression — the  head — facial  hemiatrophy — the  hair — the  cranium. 
Hydrocephalus.  The  lips.  The  eye.  The  ear.  The  neck — the  thyroid  gland,  the 
bloodvessels  of  the  neck.  The  extremities — hands,  skin,  progressive  muscular 
atrophy — lead-poisoning,  rheumatoid  arthritis,  athetosis.  Fingers.  Heberden's 
nodosities — contraction  of  fascia — Dupuytren's  contraction — deviations  in  shape. 
The  nails.  Tropho-neuroses  —  cold  hands  and  feet  —  Raynaud's  disease  — 
erythromelalgia.  The  lymphatic  glands.  The  muscles.  Myositis— idiopathic 
muscular  atrophy — pseudo-hypertrophy — Thomsen's  disease — paramyoclonus 
multiplex.  The  bones.  Nodes-  They  are  the  physical  expression  of  present 
disease,  or  of  the  ravages  of  past  affections  The  joints — synovitis — rheumatism 
— gout — rheumatoid  arthritis— the  tabetic  joint — the  hysterical  joint — special 
joint-affections.     Diagnosis. 

The  Objective  Symptoms.  The  objective  symptoms  of  disease 
are  the  most  important  to  ascertain.  They  are  the  "  handwriting  on 
the  wall."      The  impress  of  forces  for  good  or  evil  is  observed.      In 

4 


50  GENERAL  DIAGNOSIS. 

determining  them  we  determine  the  physical,  chemical,  and  vital  con- 
dition of  the  organism;  its  state  after  the  action  of  the  forces  of  its 
environment.  The  physical  and  mental  status  of  the  patient  is  measured. 
He  is  individualized.  The  objective  symptoms  are  data  by  which  a 
complete  diagnosis  is  made.  Without  such  data  the  diagnosis  is  mere 
guesswork — one  of  probability.  "With  such  data  alone,  if  accurately, 
precisely  collected,  a  positive  diagnosis  can  very  frequently  be  made. 
A  correct  diagnosis  depends  upon  the  skill  and  thoroughness  of  the 
physician  and  his  ability  to  interpret  the  data  secured,  always  provided 
that  clear,  succinct  data  can  be  obtained. 

The  data  obtained  by  inquiry  are  carefully  recorded,  after  which  the 
following  procedure  is  conducted.  A  physical  examination  of  the 
patient  is  made,  followed  by  an  immediate  study,  or,  if  time  permits, 
a  study  at  leisure  of  the  fluids  of  the  body,  microscopically,  chemically, 
and  bacteriologically.  In  the  physical  examination  we  make  a  general 
survey  of  the  individual,  and  form  an  estimate  of  his  height  and  weight. 
The  various  organs  are  interrogated  by  the  senses  applicable  to  the 
investigation  of  each,  aided  by  special  instruments.  The  natural  secre- 
tions and  discharges,  abnormal  discharges,  all  exudations  or  transuda- 
tions, and  cystic  fluids  are  passed  upon. 

The  student  will  soon  learn  that  the  process  of  ascertaining  the  objec- 
tive signs  of  disease  is  in  no  respect  different  from  that  which  obtains 
in  the  study  of  any  object  in  nature  or  any  life  phenomena.  The 
chemist  notices  the  form,  the  color,  the  density,  etc.,  of  the  object 
under  examination;  the  effects  of  heat  and  cold,  of  various  reagents 
upon  its  structure;  he  determines  its  component  parts  and  ascertains 
its  relation  to  other  objects  in  nature.  From  data  thus  obtained  by 
the  use  of  all  his  senses  he  classifies  the  object.  The  biologist  notes 
not  only  the  physical  appearance  of  a  given  form  of  life,  but  also  the 
phenomena  of  the  living,  sentient  matter  under  all  conditions  in  a 
varied  environment.  By  comparison  and  analysis  the  living  being  is 
classified. 

By  the  same  powers  of  observation  and  the  same  analytical  process, 
the  departures  from  health  are  recognized  and  classified.  Is  it  not, 
therefore,  a  wonderful  aid  to  the  diagnostician  to  possess  faculties  which 
have  been  trained  to  minute  observation  by  previous  studies  in  sciences 
allied  to  medicine  ? 

What  has  been  thus  imperfectly  said  is  intended  to  emphasize  the 
fact  that  no  mystery  attends  the  recognition  of  the  objective  signs  of 
disease.  Abundant  opportunities  of  observing  disease  at  the  bedside, 
patient  training,  skill  in  technique,  and  a  systematic  procedure  are 
essential. 

Method  of  Procedure.  The  method  by  which  the  data  ascertained 
by  observation  are  secured  is  modified  by  the  circumstances  under 
which  the  patient  is  seen.  It  is  obvious  that  the  patient  who  comes  to 
the  office,  or  is  not  sufficiently  ill  to  be  in  bed,  has  sufficient  strength 
to  stand,  and  should  be  given  an  exhaustive  examination.  Moreover, 
we  can  inquire  into  certain  abnormalities,  as  the  gait,  not  visible  in 
bed.     On  the  other  hand,  in  the  case  of  a  bed  patient,  we  learn  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  51 

position  he  assumes  when  lying  down,  and  have  better  opportunities 
tor  thorough  examination  of  the  various  organs.  Often  the  obective 
examination  must  be  very  brief  on  account  of  the  patient's  extreme 
illness.  It  may  be  advisable,  although  unfortunate,  to  exclude  one  or 
more  methods,  as  percussion,  if  there  is  pain,  or  auscultation,  if  there 
is  great  restlessness  or  orthopnoea. 

If  a  complete  examination  is  made,  it  is  well  to  begin  with  the  exte- 
rior. After  the  external  examination  is  made,  the  internal  examination 
is  conducted,  by  grouping  together  and  examining  organs  functionally 
related,  as  the  heart  and  bloodvessels,  in  diseases  of  the  heart;  the  nose, 
larynx,  and  lungs,  in  diseases  of  the  latter.  The  student  will  do  well 
to  begin  at  the  head  and  take  up  the  organs  in  their  continuity. 

Comparison.  The  results  obtained  by  observation  are  based  upon 
comparison;  the  student  must  bear  this  constantly  in  mind.  We 
compare  the  body  as  a  whole  with  our  conception  of  the  normal  individ- 
ual, formed  by  a  study  of  a  large  number  of  persons.  We  compare 
symmetrical  parts — the  right  side  of  the  chest  with  the  left,  the  arm 
suspected  to  be  the  seat  of  the  disease  with  the  healthy  arm,  etc.  The 
cardinal  rule  in  an  examination  is  to  base  the  significance  of  ascertained 
facts  upon  comparison  with  known  normal  conditions. 

Methods  of  Observation.  Securing  the  Data.  To  accomplish 
these  ends,  examination  is  made  by  the  sense  of  sight  [inspection);  by 
the  sense  of  touch  {palpation);  by  the  sense  of  hearing  {auscultation); 
and  by  the  sense  of  hearing  applied  to  the  discrimination  of  sounds 
developed  by  percussion.  By  percussion  or  tapping  the  part  we  also 
elicit  the  peculiar  phenomena  known  as  reflexes. 

The  sense  of  taste  is  not  used  to  determine  the  objective  phenomena 
of  disease.  Some  data,  such  as  the  odor  of  the  exhalations  and  dis- 
charges, are  obtained  by  the  sense  of  smell. 

Inspection.  By  inspection  we  judge  of  the  physical  condition  of 
the  whole  or  a  part  of  the  body,  as  seen  in  the  shape  and  size  and  in 
the  color;  of  the  vital  condition,  by  the  expression  of  countenance,  by 
the  character  of  the  movements  of  the  body  as  a  whole  or  in  part,  by 
the  position  in  bed,  and  by  the  gait.  The  appearance  of  fluids  (blood) 
and  of  discharges  is  also  observed.  The  results  of  inspection  as  to 
size  are  confirmed  by  actual  weighing. 

In  order  that  the  data  obtained  by  inspection  may  be  complete  and 
accurate,  every  portion  of  the  body,  and  of  its  internal  cavities  which 
can  be  seen  by  the  unaided  or  aided  eye,  should  be  inspected.  The 
clothing  should  be  removed  and,  bearing  in  mind  the  proprieties,  the 
whole  body  should  be  examined.  For  this  purpose  the  patient  should 
be  under  a  good  light.  The  light  should  always  fall  directly  on  the  sur- 
face. The  entire  surface,  of  course,  need  not  be  exposed  at  once,  and 
circumstances  may  be  such  that  only  one.  portion  need  be  examined. 
Nevertheless,  the  fact  must  be  insisted  upon  that  patients  who  have 
been  ill  for  a  considerable  time,  as  well  as  all  grave  cases,  should  be 
examined  all  over.  It  is  even  more  important  to  do  this  if  the  patient 
is  comatose.     A  node  on  the  tibia,  undue  prominence  of  the  vertebrae, 


52  GENERAL  DIAGNOSIS. 

a  special  rash  about  the  anus,  may  afford  information  which  could  not 
be  obtained  in  any  other  way.  It  is  assumed  that  the  patient  has  been 
examined  lying  down.  In  nervous  diseases  and  diseases  affecting  the 
muscles  and  bones,  the  patient's  gait,  his  ability  to  stand,  the  method 
of  rising  or  assuming  a  sitting  posture,  and  the  performance  of  other 
customary  physiological  acts  should  be  observed.  For  this  purpose, 
as  above  mentioned,  portions  of  the  body  can  be  covered,  or  a  light 
gown  thrown  over  the  patient  from  head  to  foot. 

Method  of  the  observer.  In  order  to  secure  the  data  in  full,  the  stu- 
dent should  teach  himself  a  method  of  observation  by  which  all  the  facts 
are  collated  in  regular  systematic  order.  Whether  the  examination  is 
general  or  local,  whether  the  whole  of  the  body  is  referred  to  or  only  a 
part,  as,  for  instance,  the  nose,  the  student  should  accustom  himself  to 
make  observations  in  the  following  order  :  First,  the  shape  or  contour 
(expression);  second,"  the  size;  third,  the. color;  fourth,  the  movability 
and  the  physiological  condition  of  the  part  on  movement.  If  this 
plan  is  pursued,  little,  if  anything,  will  be  overlooked.  A  similar  order 
should  be  followed  in  the  investigation  of  the  character  of  the  secretions 
and  excretions  of  the  body. 

Inspection  of  special  regions.  Iu  the  inspection  of  special  regions 
artificial  light  and  special  instruments  are  also  required.  The  artificial 
light  should  be  secured  from  an  Argand  or  Welsbach  burner  or  from  a 
gas-jet  with  a  reflector,  or  from  electricity.  To  facilitate  the  examination 
the  room  should  be  darkened  and  head-mirrors  used  as  reflectors.  A 
number  of  these  have  been  devised,  any  one  of  which  is  suitable  if  it  fits 
the  head  well  and  can  be  adjusted  with  comfort  so  that  the  observer  can 
throw  the  light  on  the  part  he  wishes  to  examine,  and,  at  the  same 
time,  peer  through  the  centre  of  the  mirror.  A  special  arrangement 
of  the  patient  and  the  light  is  required.  The  patient  should  sit  in  an 
easy,  comfortable,  erect  position,  with  the  light  on  a  level  with  the 
part  to  be  examined,  a  little  behind  and  to  his  right  or  left,  according 
to  the  convenience  of  the  examiner.  Special  apparatus  is  required  for 
the  examination  of  each  cavity  :  mirror,  tongue-depressor,  and  specula 
for  the  throat,  an  ophthalmoscope  for  the  eye,  etc.  (See  respective 
sections.) 

Palpation.  The  results  of  inspection  are  confirmed,  when  possi- 
ble, by  palpation,  and  the  sense  of  touch  supplies  additional  data. 
The  nutrition  of  the  parts  is  ascertained.  The  density,  the  resist- 
ance, the  special  character  of  the  part,  whether  solid  or  liquid, 
are  determined  by  this  method  of  examination.  On  examination 
of  the  skin  the  degree  of  dryness  or  moisture,  the  character  of  the 
skin,  whether  smooth  or  rough,  the  density  of  the  part — as  to  degree 
of  thickness  and  resistance — are  all  ascertained  by  means  of  the  sense  of 
touch.  The  presence  or  absence  of  pitting  is  observed,  and  the  nature 
of  swellings  ascertained.  In  a  similar  manner,  local  areas  are  exam- 
ined. The  same  routine  method  should  become  habitual  with  the  stu- 
dent. First,  the  shape  and  contour;  second,  the  size;  third,  the  color,  its 
change  on  pressure,  etc. ;  fourth,  the  movability  of  the  part,  and  the 
character  of  the  normal  movements,  as  when  a  joint  is  under  observa- 


THE  DA  1\  i   OB  Tu  1 IX ED  B  Y  OB  SEE  Vj  i  TION.  5  3 

tion;  fifth,  the  resistance  and  density  of  the  part  examined,  or  special 
characteristics  revealed  by  touch — the  elasticity  of  the  skin,  firmness 
of  muscles,  and,  in  swellings,  the  presence  or  absence  of  fluctuation. 
( )ther  phenomena  are  detected  which  are  vital,  in  contrast  to  the  above, 
which  are  physical.  By  palpation,  alone  or  with  instruments,  we 
determine  the  sensibility  of  the  part,  the  presence  or  absence  of  ten- 
derness, the  temperature,  and  the  degree  of  moisture.  In  the  exam- 
ination of  special  regions  by  means  of  palpation  some  phenomena  are 
determined  peculiar  to  the  system  under  examination,  and  dependent 
upon  its  physiological  or  functional  action.  Thus,  in  palpation  of  the 
chest,  in  addition  to  its  movement,  we  note  the  vibrations  transmitted 
to  the  hand  when  the  patient  is  asked  to  speak,  or  detect  abnormal 
vibrations  from  the  friction  of  two  rough  surfaces  together  (pleura),  or 
from  the  throwing  of  fluids  into  agitation :  fremitus,  friction,  and  rales 
are  thus  transmitted. 

Knowledge  of  the  action  of  the  heart  and  of  its  position  is  obtained 
by  palpation;  thrills  are  detected,  abnormal  impulses  felt.  (For  method 
of  procedure,  see  respective  organs.) 

Auscultation.  By  auscultation  we  hear  and  analyze  the  sounds 
that  attend  respiration,  the  movements  of  the  heart  and  of  the  blood 
in  the  bloodvessels.  Abnormal  sounds  may  be  created  in  the  pleura 
and  pericardium — and  in  hollow  viscera,  as  the  oesophagus,  stomach, 
and  intestines — and  their  presence  is  likewise  ascertained  by  auscul- 
tation. (See  Diseases  of  the  Lungs  and  Heart.)  The  character  of 
the  voice  as  to  the  quality  and  degree  of  loudness  is  studied  to  deter- 
mine abnormalities  in  the  respiratory  tract. 

Percussion.  By  percussion  sounds  are  elicited  which  indicate  the 
physical  condition  of  the  part  percussed.  In  health  the  lungs  and  the 
gastro-intestinal  tract  contain  air  in  certain  proportions,  and  therefore 
the  sounds  yielded  by  percussion  are  always  of  a  known  character.  Any 
change  from  the  normal  sound  is  indicative  of  disease,  of  abnormal 
structure,  or  of  alterations  in  the  normal  relations  of  the  parts.  Per- 
cussion determines  these  changes,  and,  in  addition,  enables  us  to  esti- 
mate the  size  of  organs.  It  is  possible  to  determine  the  size  of  the 
liver,  the  heart,  or  the  spleen,  because  of  the  relationship  of  these  airless, 
non-resonant  bodies  to  the  air-containing  structures  around  them.  As 
this  method  of  securing  data  is  of  greatest  use  in  pulmonary  and  abdom- 
inal diseases,  the  mode  of  procedure  will  be  described  in  the  chapters 
on  Diseases  of  the  Lungs  and  Abdomen. 

Other  Methods  to  Secure  Data.  In  addition  to  the  data 
obtained  by  the  above  methods,  valuable  and  essential  data  are  obtained 
by  chemical,  microscopical,  and  bacteriological  examinations  of  the 
fluids,  discharges,  exudations,  and  transudations,  and  by  aspiration 
and  special  examination  of  the  fluids  obtained  from  the  natural  cavi- 
ties, or  from  cysts  of  the  body.  Bacteriological  diagnosis  and  explor- 
atory puncture  will  be  considered  in  a  special  chapter. 


54  GENERAL  DIAGNOSIS. 

The  Armamentarium.  The  following  instruments  are  necessary 
to  conduct  ordinary  methods  of  investigation: 

To  aid  the  eye  we  have  the  microscope ;  various  reflectors  and  mir- 
rors to  illuminate  cavities,  as  the  ophthalmoscope,  the  laryngoscope,  and 
the  otoscope ;  specula  of  various  kinds,  and  forms  of  illumination,  as 
the  Argand  burner  and  electric  light. 

To  aid  the  touch  of  confirm  its  findings  the  thermometer,  the  tape- 
measure,  the  cyrtometer,  the  dynamometer  ;  the  plessor,  to  ascertain  re- 
flexes; the  cesthesiometer,  to  determine  the  keenness  of  sensation;  sounds 
for  the  oesophagus;  probes  for  the  nares;  the  sphygmograph  forthe  pulse. 

To  ascertain  the  nature  of  the  contents  of  a  swelling  or  tumor,  or  of 
the  natural  cavities  of  the  body,  the  exploring -needle  and  aspirator  are 
used.  The  contents  of  the  stomach,  the  bowels,  or  the  bladder  must 
be  obtained  often,  and  for  this  we  use  tubes  or  catheters,  the  fluid  being 
withdrawn  by  suction  or  by  siphonage. 

Percussion-sounds  are  elicited  by  means  of  the  plessor  and  pleximeter. 
Sounds  are  localized  and  differentiated  by  the  stethoscope,  of  which 
there  are  many  varieties.  This  instrument  is  also  employed  whenever 
auscultation  is  employed. 

For  the  examination  of  the  blood  special  instruments  are  employed 
— hcemocytometer  and  hcemoglobinometer  ;  for  the  urine  and  other  fluids, 
chemicals,  specific  gravity  bottles,  etc. ;  and  for  bacteriological  research, 
the  various  appliances  that  appertain  to  such  investigations.  The 
instruments  above  mentioned  will  be  detailed  and  their  method  of 
employment  indicated  in  the  respective  sections. 

The  Microscope.  This  instrument  is  employed  for  the  investigation 
of  the  phenomena  of  disease  in  nearly  all  the  organs  or  tissues.  It  is 
absolutely  essential  for  clinical  work.  It  need  not  be  described.  It 
is  enough  to  say  that  lenses  that  amplify  from  50  to  1500  diameters 
should  be  secured,  as  well  as  an  oil-immersion  objective  and  an  Abbe 
condenser.  '  Low  powers  are  necessary  for  the  study  of  plate-cultures, 
and  for  the  inspection  of  comparatively  large  objects  in  the  urine,  spu- 
tum, and  feces.  High  powers  are  necessary  for  bacteriological  work. 
The  diaphragms  must  be  used  with  the  Abbe  condenser. 

Data  Obtained  by  Examination  of  the  Exterior. 

The  examinations  are  made  by  inspection  and  palpation  (see  above). 
All  clothing  should  be  removed  and  the  examination  made  in  a  good 
light.  Comparisons  of  the  two  sides  of  the  body  should  always  be 
made.     The  examination  is  both  general  and  local. 

External  changes  due  to  or  associated  with  disease  of  special  systems 
are  considered  under  the  examination  of  the  systems  concerned,  as  the 
thorax,  in  the  examination  of  the  respiratory  system;  the  abdomen,  in 
the  examination  of  the  digestive  system. 

A.  General  Examination  of  the  Exterior. 

The  general  appearance  of  the  patient  affords  an  idea  of  the  ability 
he    has    to    cope    with    the    antagonistic    forces   of  his    environment, 


THE  DATA  OBTAINED  BY  OBSERVATION.  55 

or  to  overcome  the  deleterious  effects  of  his  occupation.  It  indi- 
cates the  effect  of  present  or  past  disease  or  of  inherited  disease. 
The  first  sight,  striking  impression,  is  always  to  be  noted.  "  Very 
.sick,"  "  comatose,"  "  collapsed,"  etc.,  or  "  robust,"  "  cyanosed," 
etc.,  are  speaking  memoranda.  To  the  experienced  practitioner,  the 
opinion  formed  at  first  glance  is  often  of  great  diagnostic  significance. 

We  then  note  (1)  the  temperament  and  constitution  of  the  patient  or 
the  evidence  of  any  diathesis  or  cachexia;  (2)  the  apparent  age;  (3) 
the  indications,  from  his  appearance,  of  his  habits  and  occupation;  (4) 
the  position  assumed  in  standing,  walking,  or  in  bed;  (5)  the  general 
form  and  nutrition;  (6)  the  occurrence  of  fits,  coma,  collapse,  or  shock. 

A  general  view  of  the  exterior  will  often  indicate  which  system  is 
the  probable  seat  of  the  disease.  For  instance,  violent  respiratory 
action  points  to  the  lungs  ;  paralysis,  to  the  nervous  system  ;  the 
enlarged  abdomen  to  disease  of  the  viscera  in  that  region. 

1.  The  Temperament  and  Constitution  of  the  Patient.  In 
former  times  emphasis  was  laid  upon  appearances  which  pointed  to  a 
particular  diathesis  or  type  of  inherited  constitution.  Five  varie- 
ties of  diathesis  were  described  to  which  general  appearances  pointed. 
They  were  the  gouty  or  sanguine-arthritic,  the  strumous,  the  nervous, 
the  bilious,  and  the  lymphatic.  While  certain  appearances  point  to  the 
occurrence  of  groups  of  individuals  who  may  be  classified  under  one 
of  these  diatheses,  it  is  well  not  to  lay  too  much  stress  upon  them  for 
diagnostic  purposes.  As  pointed  out  by  Gairdner,  it  is  not  proper  to 
designate  the  diathesis  off-hand.  Individual  appearances  should  be 
carefully  noted,  so  that  only  after  the  completed  examination  a  final 
conclusion  as  to  the  diathesis  can  be  drawn. 

In  the  gouty  or  sanguine  diathesis  the  osseous  system  and  muscles 
are  well  developed,  the  nutrition  active,  and  the  patient  usually  robust 
in  appearance.  The  digestion  is  good,  respirations  deep,  the  circula- 
tion is  well  carried  on,  as  shown  by  the  florid  skin  and  the  large  heart; 
the  pulse  is  firm  and  steady,  and  the  pressure  in  the  arteries  is  high. 
The  head  is  large  and  the  jaw  prominent,  the  teeth  good.  The  hair  is 
of  strong  growth.  The  individual  with  such  diathesis  is  predisposed 
to  the  arterial  changes  of  advancing  age.  Apoplexy,  aneurism,  and 
angina  pectoris,  or  complications  resulting  from  the  senile  changes  in 
the  heart  and  arteries  develop. 

Iu  the  strumous  diathesis  the  bones  and  the  glandular  system  are 
changed,  and  the  appearance  of  the  face  is  expressive;  the  bones  of  the 
chest  are  small;  the  long  bones  are  slender,  while  their  epiphyses  arc 
large;  the  forehead  is  broad  and  prominent,  the  lips  full,  the  ala?  nasi 
thick,  the  teeth  are  carious,  the  lower  jaw  light  and  thin,  the  hair 
is  fine  and  often  of  a  light  hue,  the  eyelashes  long,  the  eyebrows 
arched,  often  heavy.  In  this  diathesis  the  nutritive  changes  are  poor, 
inflammations  are  usually  sluggish;  disease  of  the  bones,  of  the  glands 
and  forms  of  tuberculosis  are  apt  to  be  more  severe. 

In  the  nervous  diathesis  we  see  small,  active,  restless  beings,  with 
small  bones  and  large  muscles.  They  are  full  of  energy,  and  carry  on 
large  business  or  mental  operations.     The  features  are  well  formed, 


oQ  GENERAL  DIAGNOSIS. 

the  eye  active.  Such  types  readily  become  the  victims  of  overwork 
and  of  early  breaking- down  of  the  nervous  system,  and  of  dyspepsia. 
They  possess  idiosyncrasies  toward  drugs,  particularly  opiates. 

In  persons  of  the  bilious  diathesis  we  find  a  dark  skin,  dark  hair, 
muddy  conjunctivae.  They  are  usually  not  well  nourished.  Their 
digestion  is  poor,  and  they  are  subject  to  attacks  of  so-called  bilious- 
ness.     Sick  headaches  are  common.      Fatigue  is  not  borne  well. 

In  the  lymphatic  diathesis  there  are  lack  of  energy  and  sluggishness 
of  nutritive  processes;  such  persons  are  unable  to  keep  up  in  the  wear 
and  tear  of  life.     They  are  usually  pallid  and  have  soft  muscles. 

In  addition  to  diathesis,  cachexia?  are  also  noted.  Cachexia?  arise 
from  the  ravages  of  disease,  especially  when  the  number  of  the  red 
cells  of  the  blood  is  reduced  and  the  haemoglobin  diminished.  Cachexias 
are  caused  especially  by  syphilis,  gout,  and  chronic  malarial  poisoning; 
in  cancer  of  some  part  of  the  digestive  apparatus — and,  indeed,  in  all 
forms  of  chronic  disease  of  the  digestive  tract — a  cachexia  is  seen. 
The  ansernia  that  arises  from  poisoning  with  lead,  arsenic,  and  other 
metallic  poisons  produces  an  appearance  to  which  the  term  cachexia 
has  been  applied,  although  in  truth  it  only  resembles  one.  Each 
form  of  cachexia  takes  its  name  from  its  cause,  as  the  syphilitic  or 
the  cancerous  cachexia. 

2.  The  Apparent  Age  of  the  patient  should  be  estimated  from  his 
appearance,  and  compared  with  the  exact  age  when  this  is  learned  later. 
In  this  way  the  physician  will  be  enabled  to  judge  whether  the  patient 
is  aging  too  rapidly  or  bearing  his  age  well.  An  obvious  advantage  of 
noting  the  patient's  age  is  that  it  enables  us  at  once  to  exclude  a  large 
number  of  diseases  which  are  not  found  in  the  period  of  life  to  which 
the  patient  belongs.  For  example,  if  the  patient  is  a  child,  we  need 
not  consider. the  chronic  degenerations  and  the  visceral  cirrhoses  which 
appear  in  middle  and  later  life.  Conversely,  in  an  old  person  we  do 
not  expect  to  meet  with  the  exanthemata  which  affect  children  almost 
exclusively.  So,  too,  typhoid  fever  and  consumption  are  more  com- 
mon in  adolescence  and  early  manhood  than  in  childhood  and  old  age. 
Again,  in  very  young  girls,  the  question  of  menstruation  and  its  diffi- 
culties never  have  to  be  considered  Gray  hair  in  a  person  under 
thirty-five  generally  indicates  a  feeble  constitution  and  premature  age. 
Loss  of  hair  is  not  significant,  for,  apart  from  a  tendency  to  baldness 
which  is  very  marked  in  some  families,  professional  men  wdio  do  much 
brain- work,  especially  in  hot,  close  rooms,  are  apt  to  become  bald  much 
sooner  than  other  men.  The  presence  of  wrinkles  at  the  corners  of 
the  eyes  and  of  "  crowds  feet,"  and  of  dull,  dry,  lustreless  eyebrows, 
should  be  noted  as  indicating  aging,  whether  the  person  has  lived  long 
or  not.  In  women  approaching  forty,  who  do  not  gain  in  flesh,  there  is 
often  a  suggestive  prominence  of  the  angles  of  the  jaw  and  sternomastoid 
muscles,  with  a  certain  loss  of  roundness  and  elasticity  of  the  cheeks. 
The  latter  appearance,  however,  may  be  due  to  loss  of  molar  teeth. 

3.  Effects  of  Habits  and  Occupation.  From  the  general  appear- 
ance, the  patient's  habits  as  to  industry,  neatness,  or  care  of  dress   may 


THE  DATA  OBTAIN  ED  BY  OBSERVATION.  57 

be  observed;  these  habits  are  of  diagnostic  importance,  particularly  in 
brain  affections.  The  appearance  also  shows  frequently  whether  the 
patient  is  addicted  to  alcohol  or  to  the  use  of  narcotics. 

The  occupation  of  the  patient  is  often  important  in  throwing  light 
upon  his  disease;  the  brown,  weather-beaten  lace  of  the  farm  laborer, 
sailor,  or  driver  contrasts  strongly  with  that  of  the  merchant,  clergy- 
man, or  clerk.  A  machinist  can  often  be  recognized  by  his  grimy, 
oily  hands.  All  this  information  can  be  obtained  at  a  glance,  and 
many  details  can  be  added  before  the  patient  has  taken  his  seat  in  the 
consulting-room. 

4.  The  Attitude  and  Gait  of  the  Patient.  The  attitude  of  the 
patient  gives  information  as  to  his  physical  vigor,  and,  to  a  certain 
extent,  of  his  alertness  of  mind.  A  man  vigorous  of  mind  and  body 
will  stand  firmly  upon  both  feet,  with  back  straight  and  shoulders 
square,  and  head  erect.  When  one  is  depressed  by  care  or  disease, 
the  shoulders  have  a  tendency  to  droop  aud  the  head  to  fall  forward. 
Indecision  and  vacillating  disposition  are  sometimes  indicated  by  the 
patient  standing  first  upon  one  foot  and  then  upon  the  other  while 
talking,  or  by  an  unsteady  look  from  the  eye. 

AVhen  one  shoulder  is  lower  than  the  other  and  the  patient  is  of 
phthisical  build,  pale,  and  emaciated,  the  attitude  is  strongly  suggestive 
of  phthisis,  or  chronic  pleurisy  on  the  side  on  which  the  shoulder  is 
depressed. 

Sometimes,  in  acute  pleurisy,  the  patient  will  walk  with  the  shoulder 
depressed  and  the  arm  firmly  pressed  against  the  affected  side,  so  as  to 
restrict  its  movements  as  much  as  possible.  Decubitus.  The  attitude 
of  the  patient  in  bed  is  often  significant.  He  may  assume  the  active 
dorsal,  or  the  side  position,  with  the  body  arranged  so  that  it  is  com- 
fortable and  unconstrained.  Then  slight  indisposition  only  is  present. 
On  the  other  hand,  the  side  position,  the  dorsal  position,  or  the  upright 
or  semi-upright  position  may  be  assumed. 

To  the  close  observer  the  attitude,  of  a  patient  in  bed  is  sometimes 
reassuring.  He  lies  easily  upon  his  back,  or  turned  slightly  to  one 
side  with  the  arms  uncovered,  and  may  even  turn  or  sit  up  to  meet  the 
physician  as  he  enters  the  room — all  these  signs  point  to  moderate 
illness  or  to  the  approach  of  convalescence. 

Side  Position.  A  patient  with  acute  pleurisy  or  pneumonia  will  lie 
on  the  affected  side  so  as  to  limit  its  motion  as  much  as  possible.  The 
breathing  will  be  shallow  and  frequent,  the  expression  of  the  face 
anxious,  and  occasionally  a  spasm  of  pain  contracts  it  as  the  patient 
coughs  or  is  obliged  to  take  a  full  breath.  He  usually  lies  on  the 
affected  side  because  fixation  is  thus  secured  and  pain  on  inspira- 
tion is  diminished,  aud  also  because  there  is  greater  liberty  fox 
expansion  of  the  free,  healthy  side.  If  effusions  are  present,  by 
lying  on  the  side  of  the  effusion  pressure  is  removed  from  the  heart 
and  the  unaffected  lung,  an  obvious  advantage. 

At  times,  in  eases  of  thoracic  aneurism,  it  situated  on  one  side,  <»r 
of  movable  thoracic  tumors,  the  patient  will  lie  on  the  side  which  is 
the  seat  of  the  disease. 


58  GENERAL  DIAGNOSIS. 

■  The  dorsal  position,  as  assumed  in  health  or  slight  disease,  has  been 
referred  to.  When  the  position  is  assumed  in  grave  disease  it  is  called 
passive  dorsal,  because  it  is  often  assumed  without  the  volition  of  the 
patient. 

In  grave  cases  of  typhoid  or  other  low  fevers  the  patient  lies 
upon  the  back  aucl  shows  a  marked  tendency  to  slip  down  in  the  bed. 
The  expression  of  the  face  is  heavy  or  vacant.  The  lips  and  teeth 
require  constant  cleansing  to  keep  them  from  sordes;  the  tongue  is  dry 
and  glazed,  or  covered  with  sordes;  the  tendons  of  the  wrists  twitch 
convulsively,  and  the  patient  lies  with  open  or  half-open  eyes  (coma 
vigil),  picking  at  the  bedclothes  or  at  imaginary  objects  which  float 
before  his  eyes. 

A  healthy  baby  a  few  months  old  finds  motion  au  almost  ceaseless 
delight.  It  will  lie  on  its  back,  kick  up  its  feet,  play  with  its  toes  or 
some  object  that  attracts  it,  crowing,  wriggling,  squirming.  In  rickets, 
on  the  contrary,  the  little  patient  lies  as  quiet  as  possible,  even  refrain- 
ing from  crying  because  all  motion  is  painful.  In  cerebro-spinal  men- 
ingitis the  head  is  drawn  backward  and  downward  and  the  muscles  at 
the  back  of  the  neck  are  rigidly  contracted. 

In  acute  disease  involving  the  peritoneum  or  neighboring  organs, 
such  as  acute  pertonitis,  appendicitis,  or  endometritis,  the  patient  lies 
on  the  back  with  the  legs  flexed  upon  the  thighs  and  the  thighs  upou 
the  abdomen.  Motion  is  avoided  as  much  as  possible,  and  so  is  any 
pressure  upon  the  abdomen. 

The  lateral  or  dorsal  position,  with  legs  drawn  up  and  trunk  and 
head  drawn  down  to  meet  them,  occurs  with  groans  of  pain  and  possibly 
involuntary  bearing-down  in  hepatic  and  intestinal  colic  and  during 
the  throes  of  labor. 

The  Semi-upright  or  Upright  Sitting  Position.  In  an  acute  attack 
of  asthma  the  patient  is  found  sitting  up  in  bed,  or  in  a  chair,  possibly 
by  an  open  window.  The  expression  of  the  face  is  anxious,  the  skin 
dusky  or  pale,  and  moist.  The  breathing  is  loud,  noisy,  and  scraping. 
The  demand  for  oxygen  is  imperative,  difficulty  is  experienced  in  inspi- 
ration and  expiration,  not  enough  air  for  physiological  purposes  being 
able  to  enter  the  alveoli;  expiration  is  prolonged  and  labored  (expiratory 
dyspnoea).  The  patient  sits  with  the  chin  raised  and  head  erect,  the 
hands  grasping  the  arms  of  a  chair  or  the  bedclothing,  so  that,  by 
fixing  the  chest,  the  accessory  muscles  of  respiration  can  be  of  the 
greatest  assistance  in  supplementing  the  diaphragm.  In  emphysema, 
in  its  late  stages,  or  when  complicated  with  bronchitis  and  asthma,  the 
same  position  is  assumed  almost  constantly. 

In  pericarditis  with  effusion,  in  large  pleural  effusions,  and  in  ad- 
vanced heart  disease  with  anasarca,  the  patient  is  unable  to  lie  down  on 
account  of  the  smothering  feeling  which  the  recumbent  position  in- 
duces. In  pericarditis  the  expression  of  the  face  is  extremely  anxious, 
the  patient  having  a  dread  of  impending  death. 

In  large  pleural  effusion  the  expression  is  not  usually  so  anxious,  but 
the  dyspnoea  may  be  intense.  The  patient  is  propped  up  in  bed,  lean- 
ing slightly  to  the  affected  side,  and  devotes  all  his  energies  to  breath- 
ing, avoiding  every  exertion,  such  as  moving,  answering  questions,  or 


THE  DATA   OBTAINED  BY  OBSERVATION  59 

coughing,  which  taxes  his  breathing-muscles  still  more.  One  side  of 
his  chest  may  be  observed  to  move  violent!)7  while  the  other  is  motion- 
less. 

In  heart  disease  and  anasarca  dyspnoea  frequently  amounts  to  orthop- 
nea. The  patient  may  be  found  propped  up  in  bed  or  seated  in  a 
large  rocking-chair,  some  patients  finding  greater  comfort  in  the  latter. 
The  face  is  pale,  livid,  or  jaundiced,  and  may  be  swollen,  while  the 
cellular  tissue  throughout  the  body  is  cedematous,  and  the  cavities,  espe- 
cially the  peritoneum,  are  more  or  less  filled  with  fluid.  In  diaphrag- 
matic pleurisy  the  position  assumed  is  very  characteristic — the  erect 
sitting  posture,  with  the  body  leaning  forward  and  laterally,  to  re- 
lieve the  pain. 

The  Prone  Position.  Rarely  the  patient  is  found  lying  upon  the 
abdomen.  He  assumes  this  position  because  it  gives  relief  to  abdom- 
inal pain  or  to  colic  of  any  form.  Owing  to  the  change  in  the  relative 
positions  of  the  organs  brought  about  by  this  posture,  the  pain  of  an 
ulcer  of  the  stomach,  of  aneurism,  or  of  caries  of  the  vertebra?  may 
be  mitigated. 

In  tetanus  opisthotonos  occurs.  The  body  rests  on  the  head  and  heels 
and  the  trunk  is  arched  upward,  because  of  tonic  contraction  of  the 
spinal  muscles.  In  strychnine-poisoning  with  tonic  convulsions  the 
same  position  may  be  assumed. 

EmprosthotonoSy  vaulted  side  position,  is  occasionally  assumed  in 
tetanus  and  also  in  strychnine-poisoning. 

Unclassified  Positions.  Irregular  or  bizarre  positions  are  usually 
assumed  in  affections  of  the  nervous  system,  particularly  in  hysteria. 

Restlessness.  Often  the  patient  is  unable  to  assume  a  position,  or,  at 
least,  to  remain  fixed  in  any  position.  This  may  occur  on  account  of 
pain,  or  because  of  irritation  or  anselnia  of  the  nerve-centres.  In  cases 
of  moderate  cerebral  hemorrhage,  and  of  shock,  there  is  great  restless- 
ness. The  patient  is  restless  without  the  appearance  of  agitation.  In 
profuse  hemorrhage,  whether  uterine,  intestinal,  or  pulmonary,  on 
account  of  cerebral  anaemia,  there  is  also  restlessness  with  sighing  and 
gasping.  The  pallor  that  attends  the  hemorrhage,  the  quickened  pulse, 
the  great  thirst,  with  the  history  of  bleeding,  are  sufficient  to  explain 
the  restless  state.  In  chorea  there  is  more  than  restlessness  :  there  is 
constant  twitching  of  muscles  with  jerking  from  one  side  of  the  body 
to  the  other.  The  patient  does  not  keep  the  covers  on  when  in  bed, 
and  by  her  jerky  movements  often  does  herself  considerable  injury. 

In  cerebral  meningitis  the  patient  tosses  from  side  to  side,  or  lies  with 
the  head  retracted  and  pressed  deeply  into  the  pillow.  The  eyes  are 
injected,  the  pupils  contracted,  and  frequent  sharp  cries  are  uttered, 
especially  if  the  patient  be  a  child. 

In  hysterical  convulsions  the  patient,  usually  a  young  woman,  tosses 
wildly  to  and  fro,  screaming,  laughing,  or  crying;  or  coma  may  be 
mimicked.  The  moods  often  change  with  great  suddenness.  The 
appearance  is  very  alarming  at  first  sight;  but  the  pulse  and  breathing 
arc  not  much  accelerated,  there  is  no  fever,  and  the  patient  is  conscious 
enough  not  to  injure  herself  even  to  the  extent  of  biting  the  tongue. 

Gait.     The  terms  astasia  and  abasia  are  applied  to  the  loss  of 


60  GENERAL  DIAGNOSIS. 

power  of  standing  and  of  walking  respectively,  without  paralysis. 
Both  are  usually  functional  or  hysterical. 

The  gait  is  sometimes  characteristic.  (See  Nervous  Diseases.)  The 
hemiplegia  patient  advances  the  sound  limb,  and  then  brings  the  other 
up  to  it  by  lifting  the  pelvis  and  swinging  the  paralyzed  limb  round  by 
a  movement  of  circumduction.  The  shoe  is  worn  down  at  the  toe  in 
an  irregular  way.  Sometimes  the  shoulder  on  the  sound  side  is  thrown 
outward  and  forward,  so  as  to  facilitate  the  raising  of  the  pelvis  on  the 
paralyzed  side  in  order  that  the  limb  may  be  circumducted.  The  arm 
may  be  rigid  or  bent  at  the  elbow,  the  fingers  being  flexed  upon  the 
palm  and  the  thumb  turned  in. 

In  locomotor  ataxia  there  is  uncertainty  in  the  gait,  which  may  only 
be  felt  by  the  patient  or  be  apparent  to  the  observer  also.  There  is 
irregularity  in  the  line  of  progression,  or  the  movements  become  very 
jerky  and  erratic.  As  there  is  very  little  motion  at  the  knee,  because 
it  is  spasmodically  braced,  the  pelvis  is  slightly  tilted  until  the  foot  is 
released;  the  foot  is  then  raised  unnecessarily  high,  jerked  rapidly  for- 
ward and  outward  and  brought  down  with  a  sudden  stamp,  or  flail-like 
action,  on  the  heel.  The  patient' s  centre  of  gravity  undergoes  several 
changes  at  each  step,  so  that  he  swings  from  side  to  side.  He  cannot 
walk  in  the  dark,  and,  at  a  later  stage,  requires  the  aid  of  canes  to 
prevent  him  from  falling  forward. 

In  paralysis  agitans  the  attitude  and  gait  of  the  patient  are  peculiar. 
The  head  and  body  are  thrown  forward  and  fixed  in  that  position;  the 
arms  are  slightly  abducted  and  partly  flexed,  the  hands  being  in  the 
position  in  which  a  pen  is  held.  The  legs  are  also  bent  at  the  knees. 
Rhythmical  tremors  affect  the  hands  first,  and  then  the  rest  of  the 
body,  the  head  and  neck  usually  escaping.  On  attempting  to  walk, 
the  gait  is  f estimating,  that  is  to  say,  each  step  becomes  more  rapid  than 
the  preceding,  until  the  patient  is  prevented  from  falling  only  by  catch- 
ing hold  of  something.  The  tremors  cease  during  sleep,  and  are  inde- 
pendent of  voluntary  motion. 

In  spastic  paraplegia  the  patient  walks  with  two  sticks.  He  leans 
on  the  left  one,  arches  the  back,  and  then  lifts  the  pelvis  and  the  right 
limb  as  far  from  the  ground  as  possible,  but  cannot  quite  clear  it.  The 
toe  has  a  marked  tendency  to  stick  to  the  ground,  and  is  brought  for- 
ward with  a  scraping  sound.  The  knees  have  a  tendency  to  interlock, 
and  the  foot  which  is  brought  forward  is  apt  to  cross  in  front  of  the  other. 

In  disseminated  insular  sclerosis  the  gait  is  somewhat  jerky  and 
resembles  the  gait  of  ataxia,  or  of  tumor  of  the  cerebellum.  Of 
course,  the  disease  that  causes  such  peculiarity  in  gait  cannot  be  estab- 
lished without  first  observing  the  mental  and  nervous  phenomena  that 
attend  such  affections. 

In  hysterical  paraplegia  there  is  sometimes  complete  loss  of  power  of 
standing  or  of  walking.  The  patient  falls  if  an  attempt  is  made  to 
compel  her  to  stand.  Or  she  walks  with  the  knees  and  the  hips  semi- 
flexed or  in  awkward  attitudes,  implying  greater  muscular  exertion 
than  necessary  for  the  normal  gait.  It  is  recognized  by  the  fact  of  its 
occurrence  in  young  subjects  in  whom  other  striking  phenomena  of 
hysteria  are  observed. 


fe 


THE  DATA  OBTAINED  BY  OBSERVATION.  61 

Cross-legged  progression.  This  form  of  gait  is  seen  in  children  with 
spastic  paraplegia,  and  occurs  because  of  contracture  in  the  calf  mus- 
cles. When  the  child  begins  to  walk,  one  foot  gets  over  in  front  of 
the  other,  or  swinging  oscillation  of  the  body  occurs,  which  may  persist 
throughout  adult  life. 

The  gait  of  pseudohypertrophic  muscular  paralysis  is  known  as  the 
waddling  gait.  This  oscillating  character  is  assumed  in  order  that  the 
body  be  so  inclined  "  as  to  bring  the  centre  of  gravity  over  each  foot 
on  which  the  patient  successively  throws  his  weight,  because  the  weak 
gluteus  medius  cannot  counteract  the  inclination  toward  the  leg  that  is 
off  the  ground,  unless  the  balance  is  exact."     (Gowers.) 

The  position  assumed  in  getting  up  from  the  floor,  as  described  by 
Gowers,  is  pathognomonic.  The  patient  turns  over  in  the  all-fours 
position,  raises  the  trunk  with  his  arms,  rests  the  trunk  upon  the  ex- 
tended hands,  then  extends  the  knees,  pushes  back  with  the  hands 
until  he  can  grasp  one  knee  with  the  corresponding  hand,  then  grasps 
the  other  knee  and  pushes  up  the  trunk  by  gradually  raising  the  point 
of  support  for  the  hand  upon  the  thigh.  The  gait  of  paramyoclonus 
multiplex  and  of  Thomsen's  disease  is  also  peculiar.     (See  Muscles.) 

Station.  Ataxic  astasia  in  locomotor  ataxia.  The  inability  to 
stand  is  observed  under  many  circumstances.  Either  with  (1)  the  eyes 
closed,  or  (2)  the  eyes  open  and  the  toes  and  heels  in  contact,  or  (3) 
with  the  eyes  open  and  feet  apart.  The  latter  occurs  in  the  highest 
degree  of  ataxia  and  may  be  followed  later  by  complete  loss  of  power 
of  standing.  Swaying.  If  a  healthy  person  stands  with  the  eyes  shut, 
the  body  will  sway  slightly.  In  a  patient  with  locomotor  ataxia  sway- 
ing; is  seen  in  increased  decree. 

.... 

In  pseudo-liypertrophic  paralysis,  if  the  patient  stands,  lordosis  is 

seen.  It  disappears  entirely  when  the  pelvis  is  supported,  which 
occurs  when  the  sitting  posture  is  assumed.  In  the  latter  stages  of 
this  affection  there  is  posterior  or  lateral  convexity  of  the  spine  with 
astasia. 

In  the  paroxysms  of  Meniere's  disease  the  loss  of  power  of  standing 
may  be  absolute.  The  patient  may  be  hurled  to  the  ground,  and  be 
quite  unable  to  rise  or  sit  up.  The  nature  of  the  paroxysm  is  sus- 
pected on  account  of  the  sudden  onset  and  the  complaint  of  vertigo, 
together  with  the  ear  symptoms  that  attend  this  affection. 

In  disease  of  the  middle  lobe  of  the  cerebellum,  swaying  from  side 
to  side,  or  in  large  waves,  is  observed.  The  appearance  is  like  that 
of  a  drunken  person.  While  the  walk  is  peculiar,  the  patient  can 
usually  sit  up. 

5.  General  Form  and  Nutrition.  The  general  form  and  nutrition 
of  the  body  are  estimated  by  the  color  of  the  skin,  the  amount  of  sub- 
cutaneous fat,  the  degree  of  muscularity,  the  size  and  shape  of  the 
osseous  system.  In  other  words,  the  degree  of  robustness  is  ascer- 
tained by  the  color  and  the  size  and  shape,  including  the  weight,  of 
the  individual.  From  the  above  inspection  we  estimate  the  degree 
of  development  of  the  individual.  To  recognize  lack  of  develop- 
ment is  often  to  be  able  to  explain  phenomena  of  a  functional  nature, 


62  GENERAL  DIAGNOSIS. 

which  otherwise  could  not  be  accounted  for.     The  color  will  be  consid- 
ered under  the  head  of  the  condition  of  the  skin. 

Importance  of  such  observation.  It  is  extremely  important  that  these 
observations  should  be  made,  particularly  in  childhood  and  adolescence. 
Not  only  are  marked  departures  from  the  normal  significant,  but  slight 
deviations  point  to  the  occurrence  of  processes  which  modify  nutrition. 
Unless  lack  of  development  is  detected,  it  is  frequently  impossible  to 
explain  the  occurrence  of  some  functional  disorder,  as  neuralgia,  or  of 
derangement  of  the  viscera,  or  of  indefinable  ill  health,  as  the  result 
of  which  the  patient  shows  inaptitude  for  exertion  or  inability  to  con- 
duct the  usual  affairs  of  life.  The  recognition  of  malnutrition,  as 
shown  in  lack  of  tone  of  muscles,  or  diminution  of  weight,  is  often 
sufficient  to  point  the  way  to  successful  treatment  by  general  methods. 

Size.  Change  in  size  may  be  general  or  local.  General  increase  or 
diminution  in  size  is  due  to  enlargement  or  diminution  of  the  bones, 
muscles,  and  fat,  singly  or  combined.  The  word  emaciation  is  applied 
to  excessive  atrophy  of  fat  and  muscles.  If  it  is  accompanied  by  great 
loss  of  strength,  the  word  marasmus  is  employed.  When  large  accu- 
mulations of  fat  take  place  the  word  obesity  is  applied  to  the  condition. 
The  estimation  of  the  patient' s  size  as  compared  with  his  weight  is  usu- 
ally based  upon  the  amount  of  subcutaneous  fat.  The  general  accu- 
mulation can  readily  be  recognized  by  rotundity  of  the  exterior. 
Variations  in  size,  however,  may  in  addition  be  due  to  changes  in  (1) 
the  skeleton,  (2)  muscles,  or  (3)  adipose  tissue,  or  (4)  to  accumulations 
of  serum,  or  (5)  abnormal  tissue,  as  mucin  underneath  the  skin,  or  (6) 
from  connective-tissue  dystrophies  in  the  same  region.  Consideration 
of  the  latter  causes  will  be  postponed;  that  which  here  follows  refers 
to  the  amount  of  fat  and,  to  a  certain  extent,  to  the  degree  of  the 
muscularity. 

Size  affords  some  information  as  to  the  degree  of  development  of  our 
patients  and  as  to  the  kind  of  diseases  to  which  they  are  most  liable. 
While  there  is  no  absolute  standard  by  which  to  compare  the  relative 
proportion  of  height  to  girth  in  individual  cases,  yet  there  is  a  type 
generally  recognized  as  being  usual,  and  variations  from  it  give  rise  to 
such  expressions  as  stout,  spare,  slender,  thin,  tall,  and  short.  Stout 
usually  expresses  an  increase  in  girth  and  a  moderate  excess  of  flesh 
over  the  normal.  When  used  in  this  sense  it  becomes  synonymous 
with  lusty,  and  indicates  an  increase  of  flesh  which  is  well  distributed 
and  due  to  healthy,  active  nutrition  without  impairment  of  physical 
activity.  In  some  cases,  especially  in  women,  stoutness  is  used  as  a 
euphemism  for  corpulency,  but  not  often  for  that  excess  of  fat  properly 
called  obesity.  Stoutness,  in  the  sense  of  lustiness,  up  to  middle  lile 
is  an  indication  of  physical  and  often  of  mental  vigor.  It  is  often 
found  in  gouty  and  rheumatic  subjects.  A  tendency  to  take  on  flesh 
after  the  age  of  forty-five,  especially  if  the  person's  occupation  is  secl- 
entery  and  his  habit  of  body  inactive,*  is  not  to  be  regarded  as  favor- 
able. It  may  be  compared  to  a  warrior's  persisting  in  wearing  an 
increasingly  heavy  weight  of  armor  after  the  campaign  is  over.  In- 
creased weight  under  such  circumstances  is  not  increased  strength,  but 
increased  burden,   and   the   burden   becomes  greater  with  advancing 


THE  DATA  OBTAINED  BY  OBSERVATION.  63 

years.  Those  who  are  under  forty  and  stout,  in  the  sense  of  having 
too  much  fat  in  proportion  to  bone  and  muscle,  bear  fevers  and  ex- 
hausting diseases  badly.  Women  at  the  menopause  are  very  prone  to  take 
on  flesh  rapidly.  Fat  subjects  after  middle  life,  and  to  an  increasing 
degree  after  that  period,  are  liable  to  fatty  degeneration  of  the  heart, 
bloodvessels,  and  important  viscera. 

Persons  who  are  tall  and  thin,  especially  if  they  have  become  tall 
rapidly  after  puberty,  are  commonly  looked  upon  as  delicate,  and  as 
especially  liable  to  consumption.  There  is  reason  for  this  view.  But 
if  they  live  to  be  twenty-five  or  more,  without  disease  of  the  lungs  or 
pleura,  they  may  then  live  to  a  great  age. 

Some  patients  have  an  appearance  which  is  well  described  and  under- 
stood by  the  word  ' '  spare. ' '  The  form  is  compactly  put  together,  but 
with  small  bones  and  a  scanty  allowance  of  fat.  There  is  a  tendency 
to  leanness  rather  than  to  roundness  of  form. 

In  still  others,  muscle  and  bone  predominate,  and  the  form  is  apt  to 
be  angular,  as  in  those  described  as  iviry.  They  are  often  possessed  of 
great  muscular  power  and  resistance  to  strain.  Those  of  spare  and 
wiry  habit  bear  disease  very  well.  Inspection  alone  may  leave  one  in 
doubt  whether  to  regard  an  individual  as  thin  and  delicate,  or  spare. 
Light  will  be  obtained  from  the  patient's  occupation  and  the  amount 
of  physical  exertion  of  which  he  is  capable,  and  also  from  the  tonicity 
and  hardness  of  his  muscles.  If  one  stops  to  think  a  moment,  he 
will  see  that,  for  the  same  amount  of  heart  and  lung  capacity,  a  man 
will  be  better  off  if  spare  than  if  corpulent ;  because,  in  the  latter  case, 
he  has  an  additional  load  to  carry,  and  he  has  to  nourish  and  keep  up 
a  thick  blanket  of  fat  from  which  he  derives  no  adequate  advantage. 
Hence  a  person  of  spare  build,  who  survives  childhood  and  adolescence 
without  disease,  probably  has,  on  the  whole,  a  better  prospect  for  long 
life  than  a  stout  person. 

Normal  Habit.  In  estimating  the  patient's  size  or  weight  it  is  im- 
portant to  ascertain  if  he  has  a  regular  habit  of  taking  on  flesh  at  cer- 
tain periods  of  the  year,  for  instance,  or  if  it  has  developed  suddenly  or 
followed  acute  disease. 

Weight.  Nothing  has  yet  been  said  of  the  weight,  but,  as  it  affords 
a  precise  estimation  of  the  size,  particularly  if  considered  in  relation 
to  the  height  and  age,  the  following  discussion  will  include  the  two 
points,  size  and  weight. 

While  the  eye  can  estimate  approximately  the  weight  of  the  body 
and  the  degree  of  emaciation,  the  physician  should  make  it  a  rule 
to  ascertain  the  weight  accurately  by  means  of  scales.  Machines  are 
now  made  which  can  be  used  for  weighing  the  patient  and,  at  the  same 
time,  noting  the  exact  height.  It  is  particularly  important  to  note  the 
weight  from  time  to  time.  In  the  course  of  wasting  disease  we  learn 
the  effects  of  treatment,  or,  on  the  other  hand,  the  march  of  disease  in 
spite  of  treatment.  In  obscure  cases,  as  in  tuberculosis,  persistent  loss 
of  flesh  is  a  serious  diagnostic  and  prognostic  symptom.  After  acute 
disease,  if  the  patient  is  weighed  every  week,  the  onset  of  insidious 
sequehe,  as  tuberculosis,  may  be  detected. 

The  relation  of  body-weight  to  height  is  of  importance.      It  is  also 


i  A  man  of  4  ft.    6  in. 

to  5  ft 

.  0 

'  "        "     5  "    0      ' 

'      5  " 

1 

it                 11           C      «         i)            I 

•     5  " 

3 

"        "     5  "    4      ' 

'     5  " 

5 

"        "     5  "    6      ' 

<     5  " 

7 

"     5  "    8      ' 

<     5  " 

9 

u        «     5  "  10      ' 

'     5  " 

11 

u        «     5  »  ii      < 

'     6  " 

0 

64  GENERAL  DIAGNOSIS. 

important  to  know  the  average  weight  of  the  individual  in  different 
periods  of  life.  The  progressive  increase  in  weight  which  should  take 
place  after  birth  should  be  remembered,  as  the  opposite  is  positive 
evidence  of  malnutrition. 

Mr.  Hutchinson's  table  enables  us  to  judge  the  average  weight  of 
a  healthy  man  of  a  given  height : 

in.  ought  to  weigh  about  92.26  lbs. 

"  115.52  " 

"    "     "    "  127.86  " 

"  139.17  " 

"    "     "     "  144.29  " 

"     "  157.76  " 

"    "     "     "  170.86  " 

u           «  177-25  «i 

In  some  life-insurance  tables  in  this  country  the  average  weight  for 
the  height  is  lower,  especially  in  persons  over  five  feet  ten  inches. 

Local  Weight  It  is  not  to  be  forgotten  that  accumulations  of  fat 
may  take  place  in  special  portions  of  the  body;  the  abdomen  is  the 
favorite  seat  for  excessive  accumulation,  particularly  in  women  and 
in  men  of  sedentary  life,  with  habits  of  excessive  indulgence  in  food 
and  drink. 

Weight  in  Disease.  The  question  of  weight  is  an  important  one  in 
disease.  As  has  been  stated,  persons  with  an  excess  of  fat  do  not  bear 
fevers  and  exhausting  processes  so  well  as  those  who  have  a  relatively 
larger  proportion  of  firm  muscles.  Remember,  if  emaciation  is  pres- 
ent, to  ascertain  its  amount  and  degree,  its  possible  relation  to  unusual 
mental  care,  or  to  acute  disease.  Slow  progressive  emaciation  is  of 
serious  moment,  as  evidence  of  tuberculosis  or  disorder  of  assimilation. 
Remember  the  wasting  that  is  associated  with  great  hunger,  excessive 
thirst,  and  polyuria  in  diabetes  mellitus.  On  the  other  hand,  such 
symptoms  as  occasional  cough,  slight  evening  fever  and  impairment  of 
resonance  at  one  apex  of  the  lung,  become  much  more  significant  of 
incipient  phthisis,  if  accompanied  by  loss  of  weight.  At  any  stage  of 
phthisis,  a  maintenance  of  the  body-weight  is  one  of  the  most  favorable 
elements  in  prognosis. 

Again,  while  loss  of  weight  attends  all  the  diseases  of  the  digestive 
tract  which  interfere  seriously  with  nutrition,  it  progresses  more  rapidly 
and  steadily,  and  attains  a  greater  degree,  in  malignant  disease  than 
in  the  mechanical  or  functional  diseases.  Hence,  the  question  of  loss 
of  weight  is  important  in  deciding  between  chronic  catarrhal  gastritis 
and  gastric  carcinoma.  But  still  more  important  is  the  question  of 
the  time  during  which  loss  of  flesh  has  been  taking  place,  and  whether 
it  has  been  progresive  or  interrupted  by  periods  of  gain  in  weight.  If 
during  two  or  three  years  the  patient  has  been  vomiting  occasionally, 
and  losing  flesh,  but  gaining  again  from  time  to  time,  it  is  much  more 
significant  of  gastric  catarrh  than  of  gastric  cancer. 

False  Increase  of  Weight.  In  certain  cases  of  great  anasarca,  and 
in  malignant  disease  of  the  abdomen,  especially  huge  cysts  of  the  ovary 
in  women,  and  sarcoma  of  the  kidney  in  children,  there  may  be  actual 
increase  of  weight  due  to  the  accumulation  of  water  or  to  the  new 
growth,  though 'the  rest  of  the  body  is  manifestly  emaciated. 


THE  DATA  OBTAINED  BY  OBSERVATION.  65 

Weight  in  Children.  In  babies  and  children  fat  is  more  likely  to- 
be  a  sign  of  good  health  than  in  adults.  Nevertheless  the  quality  of 
the  flesh  is  to  be  taken  into  consideration.  There  are  fat  and  flabby 
babies  and  children,  and  there  are  others  who  are  fat  but  whose  flesh 
has  a  firm,  solid  feel.  The  former  often  gain  and  lose  flesh  rapidly, 
and,  when  ill,  do  not  appear  to  have  much  resisting  power.  The  size 
of  a  child  gives  a  good  idea  of  its  nutrition.  A  child  may  have  its 
growth  stunted  by  bad  food  and  unfavorable  hygienic  conditions,  or 
the  stunting  may  be  the  result  of  exhausting  disease,  such  as  whooping- 
cough. 

Degree  of  Loss.  The  whole  body  may  exhibit  considerable  loss  of 
flesh,  the  cheek  bones  and  temporal  fossse  being  distinctly  visible,  the 
muscles  soft,  the  limbs  wasted,  and  the  subcutaneous  fat  diminished. 
It  is  important  to  notice  whether  flesh  has  been  lost  or  not,  and  how 
much,  and  how  long  a  time  the  loss  has  been  going  on.  Such  facts 
furnish  the  clue,  not  only  to  diagnosis,  but  to  treatment  also.  Flesh 
is  lost  in  almost  all  diseases,  acute  or  chronic,  but  it  becomes  of  special 
moment  in  diagnosis  in  the  latter.  It  is  most  noticeable  in  tubercu- 
losis, cancer,  marasmus,  cirrhosis  of  liver  and  kidneys,  diabetes,  in 
anaemias,  and  in  cachectic  conditions  due  to  prolonged  suppuration  or 
chronic  diarrhoea,  in  gastric  neurasthenia  and  anorexia  nervosa. 

Local  Change  in  Size.  There  may  be  local  increase  or  diminu- 
tion in  size,  alone  or  combined.  When  one  part  is  increased  in  size, 
and  another  growing  progressively  small,  the  disparity  indicates  dis- 
ease (see  below).  The  face  is  swollen,  especially  under  the  eyes  and 
above  the  jaws,  in  the  dropsy  of  large  white  kidney  and  in  parotitis. 
The  neck  may  be  enlarged  in  the  sterno-clavicular  notch,  or  laterally 
above  the  clavicles,  in  aneurism.  The  thyroid  as  a  whole,  or  either 
lobe,  is  enlarged  in  goitrous  affections  and  in  Graves's  disease. 

The  face  may  be  thin,  and  even  much  emaciated,  while  the  abdomen 
is  greatly  distended  from  dropsy  or  from  tumors  of  the  various  abdom- 
inal viscera  or  glands.  The  chest  is  enlarged  or  contracted.  Local 
decrease  in  size  in  thorax  or  abdomen  is  significant  of  tumors. 

The  head  is  much  increased  in  size  in  chronic  hydrocephalus,  while 
the  face  remains  small.  The  bones  of  the  cranium  are  enlarged  in 
leontiasis  ossea.  The  head,  face,  and  neck  enlarge  in  the  affection 
described  by  Allen  Starr  as  megalo-cephalie. 

The  loss  in  flesh  in  the  extremities  or  special  muscles  may  be  local 
and  atrophic  in  character,  as  in  some  diseases  of  the  nervous  system, 
such  as  neuritis,  infantile  palsy,  hemiplegia,  and  monoplegia.  Loss  of 
flesh  of  the  arms  is  said  to  be  a  symptom  in  cystic  ovarian  tumor. 

The  increase  in  size  may  also  be  local,  as  in  hydrocephalus,  elephan- 
tiasis, dystrophies,  myxcedema,  oedema,  and  various  tumors. 

Changes  in  the  Skeleton.  The  degree  of  development,  the 
size  and  the  strength  of  the  individual  in  general,  may  be  ascertained 
from  the  condition  of  the  bones  of  the  skeleton. 

Enlargement  of  the  Bones.  In  some  affections  the  bones  are  unduly 
enlarged,  modifying  the  general  form,  and  causing  increase  in  the  size 
of  the  individual. 

Acromegalia*     Marie  first  described  acromegaly,  a  remarkable  change 

5 


66  GENERAL  DIAGNOSIS. 

in  the  skeleton,  in  which  the  bones  of  the  hands,  feet,  and  face  are  par- 
ticularly the  seat  of  hypertrophy.  The  fibro-cartilages  of  the  ear  and 
larynx  also  become  enlarged.  The  enlargement  of  the  inferior  maxillary 
a  ad  frontal  bones  causes  the  face  to  assume  a  peculiar,  elongated,  ellip- 
tical outline.  The  nasal  bones  are  enlarged,  and  the  nose  thickened; 
the  temporal  fossa?  are  deepened  on  account  of  enlargement  of  the  malar 
bones.  The  forehead  retreats  because  of  the  enlargement  of  the  frontal 
sinuses  and  projection  of  the  superciliary  ridges;  the  chin  is  prominent 
and  the  lower  teeth  project  beyond  the  plane  of  the  upper:  the  lips 
and  evelids  mav  be  thickened;  the  tongue  is  enlarged  and  thickened. 
The  hair  is  coarse  and  dry;  the  face  dry  and  pigmented.  The  hands 
are  peculiar :  they  are  much  broader,  the  fingers  are  sausage-shaped, 
and  the  hand  spade-like  in  shape;  the  nails  are  flat,  striated,  and  too 
small.  There  is  usually  spinal  curvature;  the  abdomen  is  prominent, 
and,  as  before  intimated,  the  height  is  increased.  The  muscles  become 
weak  and  may  atrophy;  the  skin  is  often  pigmented;  varicose  veins 
have  been  observed,  and  the  patient  complains  of  hemorrhoids.  The 
thyroid  gland  may  be  atrophied  or  hypertrophied.  It  may  be  well  to 
state,  in  passing,  that  with  these  appearances  nervous  phenomena  are 
observed  and  disorder  of  special  senses  complained  of.  Hemianopsia, 
limitation  of  the  visual  field,  and  blindness  or  deafness  arise. 

Fig.  1. 


I 

2 

3 

Outline  of  face  in 

Outline  in  acro- 

Outline in  osteitis 

niyxoedema. 

megaly. 

deformans. 

Osteitis  deformans.  Another  remarkable  change  is  seen  in  the  skel- 
eton and  has  been  described  by  Sir  James  Paget;  in  this  there  is  marked 
change  in  the  contour  of  the  patient  and  a  peculiarity  in  the  mode  of 
locomotion.  It  is  known  as  osteitis  deformans.  The  head  is  advanced 
and  lowered,  so  that  the  neck  is  very  short,  and  the  chin,  when  the 
head  is  at  ease,  is  more  than  an  inch  below  the  top  of  the  sternum. 
The  chest  becomes  contracted,  narrow,  flattened  laterally,  deep  from 
before  backward,  and  the  movements  of  the  ribs  and  spine  are  lessened; 
the  arms  appear  unnaturally  long  ;  the  shafts  of  each  tibia  and  femur 
are  bent  so  that  the  patient  becomes  bow-legged.  There  is  some  stiff- 
ness, but  no  loss  of  power  and  not  a  great  deal  of  pain.  The  skull  is 
increased  considerably  in  thickness.  These  changes  in  the  bones  cause 
a  dwarfed  appearance  of  the  trunk  in  comparison  with  the  legs  and 
arms,  and  the  posterior  lateral  curvature  necessitates  a  characteristic 
attitude.  The  skeletal  changes  are  noted  particularly  in  the  long- 
bones.  As  a  result  of  the  enlargement  of  the  cranial  bones,  the  face 
presents  a  triangular  outline,  with  the  base  above  and  the  apex  below 


THE  DATA  OBTAINED  BY  OBSERVATION. 


67 


(see  Fig.  1,  outline  3),  thus  differing  in  appearance  from  the  outline 
in  acromegalia  (Fig.  1,  outline  2). 

Pulmonary  osteo-arthropathy.  Marie  distinguishes  acromegaly  from 
another  skeletal  change  in  which  there  is  hypertrophy  of  the  bones  of  the 
extremities,  including  enlargement  of  the  shafts.  In  this  form  of  arth- 
ropathy the  bones  of  the  head  and  face  are  not  affected.  The  hands 
and  feet  are  enlarged,  and  the  patellae  and  other  bones  of  the  knee- 
joints  increased  in  size.  Curvature  of  the  spine  is  present.  The 
appearance  of  the  fingers  is  different  from  that  seen  in  acromegalia. 
The  ends  are  enlarged  and  bulbous,  and  the  nails  are  too  large  and  are 
curved  in  a  transverse  and  longitudinal  direction,  like  the  clubbed 
fingers  of  phthisis,  although  the  chief  enlargement  of  the  fingers  is 
not  terminal,  and  there  is  no  cyanosis,  as  in  phthisical  clubbing.  The 
change  seemed  to  be  associated  with  pulmonary  affections,  and  Marie 
applied  to  it  the  name  osteo-arthropaiMe  pmewnxomque. 


Fig.  2. 


Pulmonary  osteoarthropathy.    Female,  aged  eleven.    Tuberculous  vertebral  caries  and  pulmonary 
tuberculosis.    Enlarged  fingers  and  thickened  ulna  and  radius.    Private  patient,  1885. 


Local  changes  of  the  bones  are  considered  in  the  section  on  Local 
Examination  of  the  Exterior. 

Diminution  in  Size.  Small  development  of  the  bones  is  seen  in 
idiots  and  cretins. 

Rhachitis.  In  this  affection  the  size  of  the  body  is  lessened.  For 
its  distinction,  it  is  important  to  know  how  rapidly  the  osseous  deposits 
in  childhood  have  formed.  The  fontanelles  and  the  epiphyses  must  be 
examined.      If  the  fontanelles  are  open  beyond  their  period  of  closure 


68  GENERAL  DIAGNOSIS. 

in  health,  or  if  the  epiphyses  are  enlarged  and  lack  firmness,  the  con- 
dition points  either  to  simple  malnutrition  or  to  an  affection  of  the 
bone,  known  as  rhachitis.  In  rhachitis  late  development  of  the  teeth 
is  observed.  If  the  ribs  are  examined,  nodules  will  be  detected  at  the 
junction  of  the  bone  with  the  cartilage.  These  may  be  seen,  as  well 
as  felt,  if  the  child  is  thin.  They  form  the  so-called  rhachitic  rosary. 
The  thorax  also  is  changed  in  shape.  At  the  junction  of  the  cartilages 
and  ribs  a  depression  takes  place  which  is  continuous  with  a  groove 
which  passes  out  from  the  ensiform  cartilage  toward  the  axilla.  This 
transverse  curve  is  known  as  Harrison' s  groove.  It  may  deepen  with 
inspiration.  At  the  same  time  the  sternum  projects,  forming  the  so- 
called  "pigeon-breast"  (see  Thorax).  Changes  at  the  lower  end  of 
the  radius  and  ulna,  and  sometimes  at  the  end  of  the  humerus,  are 
noticed.  The  parts  are  enlarged  at  the  junction  of  the  shaft  and  epiph- 
yses. There  may  be  thickening  of  the  clavicles  at  the  sternal  ends. 
In  the  legs  the  lower  end  of  the  tibia  becomes  enlarged,  and  at  times 
the  upper  end,  or  even  the  shait,  becomes  thickened.  The  child  be- 
comes bow-legged,  or  the  tibise  and  femora  may  arch  forward.  Knock- 
knee  sometimes  occurs.  The  bones  of  the  vertebral  column  and  of 
the  pelvis  are  also  affected.  The  spine  is  usually  curved  posteriorly, 
but  the  lateral  curvature  may  also  be  produced  with  it.  The  contrac- 
tion of  the  pelvis  is  such  as  to  narrow  its  outlet — a  matter  of  much 
importance  lor  the  future  of  female  children. 

The  head  of  the  child  with  rickets  is  quite  characteristic.  It  has 
been  mentioned  that  the  fontanelles  remain  open  for  a  long  time,  and 
areas  of  ossification  are  imperfect,  so  that  the  bone  yields  to  the  pres- 
sure of  the  finger.  This  occurs  particularly  at  the  side,  and  the  term 
cranio-tabes  is  applied  to  it.  The  large  head  is  square  in  shape,  when 
seen  from  above  downward.  It  gives  the  face  a  peculiar  appearance. 
It  is  proportionately  very  small,  especially  in  the  lower  two-thirds, 
while  the  forehead  is  broad  and  square. 

The  condition  is  not  difficult  of  recognition  if  the  general  and  local 
appearances  just  indicated  are  associated  with  the  symptoms  of  the 
disease  (see  Rhachitis). 

Osteomalacia.  Among  the  general  affections  of  the  skeleton  which 
may  cause  lessened  size,  osteomalacia  must  not  be  forgotten.  As  the 
lime  salts  are  dissolved,  the  bones  become  preternaturally  soft,  break 
on  the  slightest  provocation  or  bend  in  various  directions,  depending 
upon  the  external  pressure  and  the  direction  of  the  muscular  force. 
The  ribs  are  drawn  in  by  inspiratory  force  until  the  cavity  of  the 
thorax  is  lessened  to  a  degree  incompatible  with  life.  The  pelvis  is 
deformed  so  that  labor  is  impossible.  (It  occurs  frequently  in  preg- 
nancy.) All  sorts  of  fixed  contortions  are  assumed.  If  the  patient 
is  able  to  be  up,  the  body  shortens,  the  back  becomes  rounded,  the  neck 
flexed  so  that  the  chin  is  brought  close  to  the  sternum.  On  palpation, 
the  bones  can  be  indented  with  the  finger,  and  crepitate  like  eggshells. 

Osteomalacia  is  easily  distinguished  from  carcinoma  or  sarcoma  of 
the  bones.  In  the  latter,  spontaneous  fracture  occurs  in  various  parts 
of  the  skeleton,  but  is  generally  preceded  by  pain  and  swelling  at  the 
seat  of  fracture.      Then,  in  sarcoma,   subcutaneous  hemorrhages  are 


THE  DATA  OBTAINED  BY  OBSERVATION.  69 

present.     When  a  single  joint  is  affected  in  osteo-sarcoma  the  same 
eggshell  crackling  is  observed. 

6.  The  Exterior  in  General.  The  Skin.  Inspection.  The  ex- 
ternal examination  reveals  the  color  of  the  skin,  the  presence  of  erup- 
tions, of  hemorrhages,  and  of  scars.  The  nutrition,  the  degree  of 
moisture,  and  the  temperature  are  observed  by  palpation. 

Color.  The  portions  exposed  to  the  air  exhibit  more  varied  and 
pronounced  changes  of  color  than  parts  that  are  covered.  It  is  under- 
stood that  the  changes  in  color  herein  described  refer  more  particularly 
to  the  face  and  hands,  and  that  the  color  of  other  parts  partakes  of  the 
same  tint  as  that  of  the  face,  other  things  being  equal,  except  that  the 
intensity  is  less.  Comparison  of  the  two  should  always  be  made,  and 
the  mucous  membranes  examined,  as  control-observations.  For  the 
latter  the  conjunctivae,  lips,  and  mouth  are  sufficient,  always  remem- 
bering the  possibility  of  hypersemia  of  the  conjunctiva  from  other 
causes. 

Local  changes  of  the  face  will  be  particularized  in  this  section.  It 
is  not  to  be  forgotten  that  the  color  varies  with  the  type — whether 
blonde  or  brunette — and  that  variations  in  the  latter  at  times  easily 
escape  recognition. 

The  skin  in  a  healthy  child  is  of  a  faint  pink  color;  as  age  advances, 
it  loses  its  fresh  appearance  and  becomes  paler,  except  in  those  wdiose 
occupation  exposes  them  to  atmospheric  influences.  In  the  latter,  the 
skin  becomes  weather-stained,  and  may  assume  a  mahogany  or  reddish- 
brown  hue.  In  old  age,  the  color  is  apt  to  deepen  and  become  duller, 
while  the  loss  of  subcutaneous  fat  allows  the  skin  to  lie  in  folds,  espe- 
cially about  the  jaws  and  neck,  and  wrinkles  are  marked,  especially 
between  the  eyebrows,  over  the  nose,  and  at  the  angles  of  the  eyes  and 
mouth. 

Apart  from  these  changes,  which  are  physiological  or  necessarily  the 
result  of  occupation,  the  skin  exhibits  changes  which  are  the  result  of 
the  habits  or  health  of  the  individual.  Some  persons,  especially  if 
blondes,  retain  to  old  age  the  fresh,  pink  skin  of  childhood.  In  others 
is  seen  early  a  dull,  muddy  complexion.  This  is  common  in  those  who 
use  coffee  to  excess  and  are  habitually  constipated.  In  others  digestive 
derangements,  particularly  constipation,  produce,  in  addition  to  a 
muddy  complexion,  crops  of  acne  and  comedones  or  black-heads.  It 
must  be  admitted,  however,  that  some  persons  preserve  a  fresh  com- 
plexion in  spite  of  marked  digestive  disturbance.  Considerable  con- 
gestion of  the  superficial  bloodvessels,  giving  a  person  a  florid  appear- 
ance, may  be  due,  especially  in  a  young  person,  to  alcoholic  excesses; 
and  there  is  a  popular  belief  which  connects  such  an  appearance,  when 
coupled  with  a  tuherous  nose  and  a  crop  of  angry-looking  pustules, 
with  a  prolonged  use  of  spirits. 

Color  Increased.  The  abnormally  red  skin.  Physiological  hyper- 
aemia  has  been  spoken  of.  The  color  is  intensified  when  the  capillaries 
are  overfilled,  or  the  blood-current  is  unusually  rapid.  The  hypersemia 
may  be  general  or  local,  and  is  due  to  dilatation  of  the  capillaries, 
possibly  from  nerve-influences.     General  hyperemia  is  seen  in  lever, 


70  GENERAL  DIAGNOSIS. 

in  poisoning  from  atropine,  and  from  organic  poisons  derived  from  food 
or  the  result  of  intestinal  putrefaction. 

Local  hyperaemia  attends  the  phenomena  of  blushing  and  comes  and 
goes  in  nervous  persons  with  every  psychical  impression.  Abnormal 
redness  may  be  diffused  over  the  whole  face  or  may  present  the  circum- 
scribed flush  of  phthisis;  the  local  deep-red  area,  on  one  cheek,  of 
pneumonia;  the  evanescent  flush  of  anaemia,  with  cardiac  palpitation; 
and  the  creeping  flush,  with  raised  border,  of  erysipelas,  appearing  on 
the  bridge  of  the  nose  or  at  the  nostril.  In  phthisis,  small  excite- 
ment or  exertion,  the  taking  of  food,  or  the  onset  of  fever,  tinges  the 
cheek  with  the  blush  of  hectic.  In  migraine,  the  burning  flush  may 
be  limited  to  one  side.  Capillary  congestion  on  the  cheeks  or  on  the 
tip  of  the  nose  occurs  with  the  endarteritis  of  the  aged,  but  is  seen 
also  in  earlier  life  in  cases  of  hepatic  cirrhosis,  or  of  obstruction  of 
the  hepatic  circulation  from  other  causes. 

Color  Lessened.  It  is  caused  by  diminution  of  the  amount  of 
blood  in  the  capillaries,  or  because  its  richness  in  haemoglobin  has  been 
reduced. 

Pallor.  Diminished  amount  of  blood  in  the  capillaries  occurs  from 
active  contraction  or  spasm  of  the  arterioles,  from  hemorrhage,  or 
from  weak  heart.  The  pallor  that  arises,  therefore,  is  usually  acute 
or  temporary,  and  may  be  recurrent.  It  results  from  fright,  syn- 
cope, or  nausea  and  vomiting.  It  occurs  also  in  acute  poisoning,  in 
acute  disease,  such  as  diphtheria,  and  in  hemorrhage.  The  pallor  that 
arises  from  hemorrhage  comes  on  more  gradually — that  is,  in  the  course 
of  an  hour  or  more,  or  during  three  or  four  days.  Of  course,  if  the 
hemorrhage  is  excessive,  the  pallor  may  come  on  in  a  few  minutes. 
The  onset  of  sudden  pallor  in  diseases  in  which  hemorrhage  may  be 
feared  is  of  diagnostic  significance,  as  in  aneurism,  gastric  or  intestinal 
ulcer,  and  typhoid  fever.  If  due  to  hemorrhage,  the  symptoms  of 
collapse  are  seen  with  the  onset  of  the  pallor. 

Pallor  of  long  duration,  or  chronic  pallor,  if  we  may  so  term  it,  is 
seen  in  a  number  of  diseases.  In  all  of  them  there  are  diminution  in 
the  amount  of  red  corpuscles  and  destruction  of  the  haemoglobin.  It 
is  characteristic  of  blood  affections,  as  the  various  forms  of  anaemia. 
It  does  not  necessarily  occur  in  leucaemia  ;  indeed,  the  cheeks  and  lips 
may  be  red.  It  is  seen,  in  a  striking  form,  in  chronic  Bright' s  disease, 
in  cancer,  in  chronic  poisoning,  as  from  lead  or  arsenic,  in  chronic 
catarrh  of  the  stomach  or  of  the  bowels,  and  in  chronic  infectious 
processes,  as  tuberculosis  and  syphilis. 

AVhile  paleness  is  recognized  as  the  fundamental  or  prevailing  color 
of  the  skin  in  many  of  the  above-noted  affections,  a  further  tinge  gives 
a  characteristic  hue  to  the  skin;  thus,  in  chlorosis  there  is,  a  greenish 
appearance  of  the  face,  which  is  in  striking  contrast  to  the  pearly 
colored  conjunctivae.  In  carcinoma  the  yellowish  tinge  of  the  pallor 
often  causes  it  to  be  mistaken  for  jaundice.  In  pernicious  ancemia  a 
straw-colored  appearance  of  the  skin  has  been  frequently  described, 
which  may  cause  it  to  be  mistaken  for  carcinoma.  It  is  worthy  of 
remark  that  the  cachectic  pallor  in  carcinoma  is  not  likely  to  occur, 
uuless  there  are  primary  or  secondary  deposits  in  the  gastro-intestinal 


THE  DATA   OBTAINED  BY  OBSERVATION.  71 

tract  or  the  liver,  and  it  is  well  known  that  pernicious  anaemia  is  usu- 
ally secondary  to  gastric  or  hepatic  disorder.  The  peculiar  hue  of  the 
pallor,  therefore,  may  be  due  to  a  common  cause  in  these  affections. 
The  pallor  that  attends  Bright' 's  disease  is  usually  associated  with  slight 
puffiness  under  the  eyelids,  or  local  dropsical  accumulations  elsewhere. 
In  chronic  poisoning  with  lend  pallor  is  associated  with  a  blue  line 
upon  the  gums  and  drop-wrist;  while  in  arsenical  poisoning  there  are 
frequently  associated  a  puffiness  of  the  eyelids  and  looseness  of  the 
bowels. 

It  is  not  well  to  lay  much  stress  upon  the  variations  in  hue  of  the 
pallor.  They  are  not  of  diagnostic  importance  in  themselves,  but  only 
when  associated  with  the  characteristic  symptoms  and  signs  of  the 
respective  affections  in  which  this  hue  occurs. 

It  must  not  be  forgotten  that  there  are  a  large  number  of  individuals 
in  whom  pallor  is  the  normal  condition.  This  is  particularly  the  case 
with  those  who  lead  a  sedentary  life  and  are  confined  within  doors. 
There  are  a  number  of  occupations  which  predispose  to  pallor. 

Abxoemal  Color.  The  Yellow  Skin.  Jaundice.  Jaundice  is  a 
symptom  due  to  a  number  of  diseases.  In  the  first  place,  it  is  most 
frequently  due  to  disease  of  the  liver;  this  form  is  known  as  hepato- 
genous jaundice.  It  may  possibly  be  due  to  destruction  of  the  cor- 
puscles of  the  blood  and  liberation  of  the  haemoglobin,  the  so-called 
hoemcdogenous  jaundice.  The  various  causes  of  the  former  will  be 
considered  under  diseases  of  the  liver.  The  latter  is  said,  not  without 
objection,  to  be  due  to  destructive  agencies  in  the  blood,  such  as  pto- 
maines, which  are  absorbed  in  gastro-intestinal  disease,  or  to  poisons 
that  develop  in  the  course  of  pyaemia,  yellow  fever,  malarial  and  re- 
lapsing fevers;  it  may  also  be  due  to  snake-bite  or  to  poisons  that  are 
imported,  as  in  mineral  poisonings,  or  chloroform,  ether,  or  chloral. 

In  both  instances  the  yellow  coloration  of  the  skin  is  due  to  coloring- 
matter  of  the  bile  or  of  the  blood,  or  bilirubin,  which  is  deposited  in  the 
cells  of  the  rete  mucosum.  The  yellow  coloration  is  seen  not  only  in 
the  skin,  but  in  the  sclerae  (see  the  Eye)  and  the  mucous  membranes. 
The  discoloration  of  the  skin  is  not  difficult  of  recognition.  It  varies 
in  shades  from  a  slight  yellow  hue  to  yellow-  or  olive-green,  and  in  many 
forms  of  jaundice  to  brownish-yellow.  The  yellow  hue  of  the  skin  in 
jaundice  may  be  preceded  and  is  always  accompanied  by  tingeing  of 
the  conjunctivae;  its  presence  in  this  situation  confirms  the  observation. 
The  mucous  membrane  under  the  tongue  early  gives  evidence  of  jaun- 
dice. Or,  if  the  lips  are  everted  and  a  glass  slide  pressed  evenly 
on  the  surface,  the  yellow  discoloration  of  the  mucous  membrane  will 
shine  through. 

The  yellow  tint  of  the  conjunctivae  must  not  be  confounded  with  the 
same  color  due  to  subconjunctival  fat.  The  latter  is  not  uniform  in 
the  conjunctivae,  and  may  be  seen  to  occupy  cone-shaped  areas. 

The  physiological  yellow  color  of  the  skin  that  is  seen  in  infants 
shortly  after  birth  is  not  a  true  jaundice,  but  in  all  probability  arises 
from  excessive  destruction  of  red  corpuscles  in  the  over-congested  -kin. 
On  light  pressure  with  the  finger  the  color  changes.  It  fades  from 
shades  of  yellow  into  the  genuine  flesh-color.     The  conjunctivae  are 


72  GENERAL  DIAGNOSIS. 

natural,  and  the  urine  is  free  from  bile-pigment.      The  faeces  are  nor- 
mal.    By  these  symptoms  a  distinction  can  be  made. 

Other  symptoms  due  to  the  same  cause  are  associated  with  hepatoge- 
nous jaundice.  Their  presence  may  be  of  diagnostic  value  in  determining 
the  nature  of  the  yellow  color  of  the  skin  in  cases  of  doubt.  These  symp- 
toms are:  (1)  Itching.  This  symptom  is  intolerable ;  the  surface  of  the 
body  is  often  seen  to  be  covered  with  scratch -marks  on  account  of  the 
irritation  of  the  peripheral  ends  of  the  nerves  in  the  skin  by  bile-pig- 
ment. (2)  Slow  puke.  Slowness  of  the  pulse  also  frequently  attends 
jaundice.  (3)  Secretions  and  excretions.  The  saliva,  or  expectoration, 
if  present,  is  bile-tinged,  and  the  urine  is  dark-colored,  due  to  the 
presence  of  the  pigment.  (See  Urine.)  While  the  excretions  are  all 
tinged  with  bile  in  the  hepatogenous  form,  the  faces  are  free  from  bile, 
hence  they  are  pale  or  of  an  ashy  color.  On  account  of  the  absence 
of  bile  in  the  intestines  its  physiological  effects  are  lost,  and  therefore 
flatulency  from  fermentation  becomes  an  importaut  symptom. 

The  Blue  Skin.  Cyanosis.  This  peculiar  hue  is  recognized  without 
difficulty.  The  bluish  or  bluish-red  appearance  of  the  skin  is  first 
seen  at  points  furthest  from  the  central  organ  of  circulation,  as  in  the 
extremities.  The  mucous  membranes,  in  which  the  capillary  circula- 
tion is  readily  seen,  also  exhibit  the  change  early.  It  is  early  seen 
also  in  the  finger-tips,  particularly  underneath  the  nails,  about  the 
phalangeal  joints,  and  in  the  lips.  Subsecmently  the  entire  surface 
of  the  skin  may  become  dusky  or  cyanosed,  as  its  cause  increases  in 
degree.  Its  onset,  it  is  said,  can  be  anticipated  by  the  state  of  the 
veins  on  the  under  part  of  the  tongue;  overfilling  or  extreme  disten- 
tion of  these  vessels  always  occurs  in  cyanosis.  At  first  the  color, 
wherever  situated,  usually  disappears  on  pressure,  but  as  the  hue 
deepens  it  remains  in  spite  of  pressure. 

Causes.  '  Cyanosis  is  due  (1)  to  overfilling  of  the  veins  and  capillaries 
with  blood  not  sufficiently  oxygenated,  or  (2)  to  an  excess  of  venous 
blood,  oxygenation  not  being  interfered  with. 

1.  All  conditions  which  interfere  with  the  aeration  of  the  blood  lead 
to  the  development  of  cyanosis.  Practically  sufficient  air  cannot  get 
to  the  blood,  or  sufficient  blood  to  the  air.  Obstruction  of  the  air- 
passages,  diminution  of  respirator}''  area,  and  diminished  or  ineffi- 
cient respiratory  movements  prevent  oxygen  getting  to  the  blood  ; 
interference  with  the  circulation  in  the  lungs  prevents  the  blood  getting 
air.     Both  causes  are  often  combined. 

a.  Obstruction  of  the  Air-passages.  This  may  occur  in  the  upper 
respiratory  tract,  or  in  the  capillary  bronchi.  (1)  Faucial  obstruction, 
by  pharyngeal  abscess  or  tonsillitis,  or,  in  rare  cases,  by  diphtheria, 
causes  moderate  cyanosis.  (2)  Obstructive  laryngeal  diseases  produce 
cyanosis  varying  in  degree  with  the  amount  of  obstruction  and  its  per- 
sistence. The  cyanosis  is  of  short  duration  in  spasmodic  croup  and 
in  laryngismus  stridulus;  it  is  prolonged  in  the  more  persistent  inflam- 
matory affections.  Its  gradual  onset,  in  moderate  degree,  as  seen  by  the 
purple  lips  or  dusky  finger-tips,  is  of  serious  prognostic  import  in  the 
course  of  tuberculous  laryngitis,  even  if  symptoms  of  grave  obstruction 
have  not  arisen.     (3)  Tumors,  pressing  on  the  trachea  or  bronchi,  nar- 


THE  DATA  OBTAINED  BY  OBSERVATION.  73 

rowing  the  air-channel,  cause  cyanosis.  The  tumors  may  be  situated  in 
the  neck,  as  the  thyroid  gland,  or  within  the  mediastinum.  (4)  Spasm  of 
the  bronchi,  as  in  asthma,  occlusion  of  the  bronchioles,  as  iu  bronchitis, 
both  acute  and  chronic,  and  particularly  the  grave  forms  of  capillary 
bronchitis  in  childhood,  cause  cyanosis.  (5)  Foreign  bodies  anywhere 
in  the  upper  regions  of  the  respiratory  tract  are  fruitful  sources  of 
cyanosis. 

b.  Diminution  of  the  Respiratory  Area.  Cyanosis  from  this  cause 
occurs  in  pneumonia,  in  oedema  of  the  lungs,  in  tuberculosis,  and  in  all 
forms  of  pleural  effusion  and  of  intrathoracic  tumors  compressing  the 
lung.     It  is  an  important  diagnostic  feature  of  acute  tuberculosis. 

c.  Diminished  or  Insufficient  Respiratory  Movements.  Deficient 
chest-expansion,  because  the  action  of  the  respiratory  muscles  is  inter- 
fered with,  lessens  the  respiratory  area.  This  interference  may  be  either 
on  account  of  muscular  or  pleuritic  pain,  on  account  of  paralysis,  or, 
in  the  case  of  the  diaphragm,  on  account  of  upward  pressure  by  accu- 
mulations in  the  abdominal  cavity,  as  large  peritoneal  effusions,  an 
enlarged  liver  or  spleen,  or  an  abdominal  tumor.  In  bulbar  paralysis 
and  peripheral  neuritis,  in  paralysis  of  the  diaphragm,  and  in  spasm 
of  the  muscles  of  respiration  (as  in  tetanus)  there  is  diminished  respira- 
tory movement.  In  forms  of  progressive  muscular  atrophy  and  in 
other  rare  affections  of  the  muscles,  as  trichinosis,  cyanosis  is  also 
observed  for  the  same  reasons. 

d.  Interference  with  the  Circulation  within  the  Lungs,  from  pressure  on 
the  pulmonary  artery  or  vein  by  aneurism  or  mediastinal  tumor,  or 
from  diseases  of  the  heart  itself,  is  a  most  frequent  cause  of  cyanosis. 
In  affections  of  the  heart  it  is  not  seen  until — in  the  case  of  valvular 
disease,  for  instance — compensation  is  lost  and  the  right  heart  is 
dilated,  causing  an  accumulation  of  blood  in  the  lungs.  In  the  latter 
condition  the  bronchitis  of  passive  congestion  of  the  mucous  membrane 
is  an  additional  cause  for  the  cyanosis. 

2.  Obstruction  to  the  Flow  of  Venous  Blood  anywhere  in  the  circu- 
lation will  lead  to  the  development  of  cyanosis.  This  is  the  cyauosis 
of  passive  congestion.  Cyanosis  due  to  causes  enumerated  under  1 
is  always  geueral.  Cyanosis  arising  from  causes  which  will  be  indi- 
cated in  this  section  may  be  general  or  local,  depending  upon  the  seat 
of  obstruction.  General  cyanosis  may  occur  in  (1)  congenital  heart 
disease  ;  (2)  in  valvulitis,  when  compensation  is  lost  and  dilatation 
has  taken  place  ;  (3)  in  incompetency  of  the  valves  from  dilatation  ; 
(4)  in  weak  heart,  or  enfeebled  action  from  pericardial  effusion.  In 
congenital  heart  disease  the  cyanosis  is  so  great  and  so  persistent 
that  the  affection  has  been  termed  "blue  disease"  or  "morbus 
caeruleus." 

Local  cyanosis  is  seen  when  there  is  obstruction  of  the  venous 
trunks  from  external  pressure,  or  from  diseases  of  the  venous  wall, 
causing  thrombosis.  It  may  be  limited  to  the  head  and  upper 
extremities,  in  obstruction  of  the  descending  cava  by  tumor  or  aneur- 
ism, or  to  the  lower  portion  of  the  trunk  and  the  lower  extremities 
in  obstruction  of  the  ascending  cava  by  pressure  from  tumors  within 
the  abdomen  and  thorax.     One  extremity  may  be  the  seat  of  local 


74  GENERAL  DIAGNOSIS. 

venous  stasis  from  pressure  upon  the  vein,  or  its  occlusion  by  throm- 
bosis :  the  arm  in  cases  of  cancer  of  the  breast  and  axillary  glands,  the 
leg  in  cases  of  femoral  phlebitis,  represent  typical  forrns  of  venous 
stasis.  A  striking  form  is  due  to  causes  affecting  the  vasomotor  nerves, 
giving  rise  to  peripheral  capillary  spasm.  (See  under  Fingers,  Ray- 
naud's Disease.) 

The  Bronzed,  Skin.  Pigmentation.  The  most  marked  form  of  bronz- 
ing is  seen  in  Addison's  disease.  The  external  surfaces  are  changed 
in  hue,  and  delicate  portions  of  the  skin  underneath  the  clothing  are 
also  bronzed.  The  discoloration  is  not  removed  by  pressure.  The 
areas  are  irregular  in  shape.  The  skin  is  soft  and  pliable.  The  pig- 
ment which  causes  the  discoloration  is  deposited  in  the  rete  Malpighii. 

The  pigmentation  is  never  seen  in  the  cornea  or  in  the  nails.  The 
axilla,  the  flexure  of  joints,  the  median  line,  the  areola  about  the  nip- 
ple and  other  normal  areas  of  pigment  deposit  are  the  seat  of  this 
deposition  of  pigment.  In  the  mucous  membranes  the  bronzed  areas 
are  limited  to  patches;  they  are  sharply  circumscribed,  brown  areas, 
seen  in  the  mucous  membrane  of  the  lips  and  cheeks. 

The  discoloration  of  the  skin  in  Addison's  disease  must  not  be  con- 
founded with  a  similar  discoloration  that  occurs  on  account  of  sun- 
burn. The  discoloration  under  the  latter  circumstance  is  limited  to 
parts  that  are  exposed  to  the  sun,  is  more  uniform,  and  the  mucous 
membranes  are  free.  Moreover,  the  anaemia  and  debility  of  Addison' s 
disease  do  not  attend  it.  The  pigmented  areas  in  the  mucous  mem- 
brane of  the  mouth  seen  in  a  certain  class  of  negroes  must  not  be 
mistaken  for  the  pigmentation  of  Addison's  disease. 

In  persons  living  in  filth  general  discoloration  of  the  skin  takes 
place,  known  as  "  vagabond's  disease  ;"  but,  because  it  is  so  general 
and  the  skin  is  rough  and  thickened,  and  other  evidences  of  filth  are 
seen,  it  can  easily  be  recognized.  In  the  latter  stages  of  jaundice  the 
dark-green,  olive,  or  black  hue  of  the  skin  might  be  taken  for  the 
general  bronzing  of  Addison's  disease.  The  appearance  of  the  con- 
junctiva is  sufficient  to  indicate  the  cause  of  the  bronzing.  In  certain 
cases  of  tuberculous  peritonitis,  even  if  the  adrenals  are  not  involved, 
the  peculiar  brown  discoloration  which  simulates  Addison's  disease  is 
present.      In  scleroderma  rarely  pigmentation  occurs. 

The  pigmentation  that  occurs  in  uterine  disease  or  in  pregnancy 
(uterine  chloasma)  frequently  resembles  the  bronzing  of  Addison's 
disease.  It  is  usually  confined  to  the  forehead  and  cheeks  and  the 
normal  pigmentary  areas  of  the  skin.  The  mucous  membranes  are 
not  affected,  although  in  pregnancy  there  may  be  the  characteristic 
change  of  the  vaginal  mucous  membrane.  In  both  uterine  disease 
and  pregnancy  the  general  conditions  that  attend  disease  of  the  supra- 
renal capsule  are  absent. 

The  bronzing  of  Addison's  disease,  the  pigmentation  of  "  vagabond's 
disease"  and  of  pregnancy  must  not  be  confounded  with  the  discolora- 
tion— yellowish-brown  in  hue — of  tinea  versicolor,  a  parasitic  skin  dis- 
ease. The  latter  is  recognized  by  its  color  and  irregular  dissemination. 
It  especially  occupies  the  chest  and  spreads  to  the  abdomen.  It  rarely 
ascends  above  the  neck.      It  does  not  usually,  therefore,  occur  in  parts 


THE  DATA  OBTAINED  BY  OBSERVATION.  75 

exposed  to  the  air,  or  in  parts  that  are  the  seat  of  normal  pigmentation. 
Then,  again,  the  surface  desquamates  in  brownish  scales.  Examination 
of  the  scales  in  a  drop  of  dilute  liquor  potassse,  under  the  microscope, 
shows  both  spores  and  mycelium.  The  spores  are  of  the  fungus  micro- 
sporon  furfur. 

It  must  not  be  forgotten  that  there  are  cases  of  Addison's  disease 
without  the  occurrence  of  the  peculiar  bronzing.  The  disease  of  the 
supra-renal  capsule,  which  is  most  frequently  attended  by  the  discolora- 
tion, is  tuberculosis.  At  times  the  bronzing  and  other  characteristic 
symptoms  of  the  disease  are  associated  with  tuberculosis  in  other  organs. 
Conversely,  in  cases  of  phthisis  in  which  there  is  bronzing,  tuberculous 
disease  of  the  supra-renal  capsules  may  be  suspected,  and  it  adds  to 
the  gravity  of  the  prognosis.  " 

Argyria.  If  nitrate  of  silver  is  administered  over  a  long  period  of 
time,  fine  black  particles  of  the  metal  or  of  the  albuminate  are  depos- 
ited in  the  kidneys,  the  intestine,  and  the  skin.  The  corium  is  the 
principal  seat  of  the  deposition.  The  discoloration  of  the  skin  is  gray 
or  grayish-black.  It  is  not  changed  by  pressure,  and  is  usually  limited 
to  the  face  and  hands.  Small  specks  may  also  be  noted  in  the  mucous 
membrane  of  the  mouth.  The  cornea  and  nails  are  not  affected.  Per- 
sons are  usually  in  good  health,  although  the  presence  of  the  skin- 
chauge,  if  seen  in  a  patient  with  coma,  would  point  to  the  possible 
presence  of  epilepsy,  on  account  of  which  the  drug  had  been  taken. 

Freckles.  Freckles  are  not  usually  of  special  diagnostic  significance. 
Their  occurrence  in  an  unusual  degree  on  the  back  of  the  hand  and 
forearm  has  been  observed,  however,  in  cases  of  rheumatoid  arthritis. 

Hemorrhages— Purpura.  Hemorrhages  in  the  skin  are  called, 
according  to  their  size,  petechias,  ecchymoses,  vibices,  and  hcematomala. 
The  petechise  and  ecchymoses  are  apt  to  appear  in  the  hair  follicles, 
and  vary  in  size  from  a  pin-point  to  a  split  pea.  They  must  be  dis- 
tinguished from  erythematous  and  other  eruptions. 

Mode  of  Recognition.  They  may  be  raised  above  the  surface  of  the 
skin;  they  do  not  disappear  upon  pressure,  and  vary  in  hue  from  deep 
red  to  yellow-brown,  according  to  their  depth  beneath  the  surface  and 
to  the  degree  of  absorption  that  has  taken  place  since  the  hemorrhage 
occurred. 

Vierordt  advises  the  following  test  to  distinguish  them  from  ery- 
themas :  Press  a  piece  of  glass  (a  microscope  slide)  upon  the  suspected 
spot.  A  hemorrhage  is  rendered  more  distinct,  while  the  surrounding 
part  becomes  more  anaemic.  An  inflammatory  hypersemia,  on  the 
other  hand,  disappears. 

Cause.  Hemorrhages  may  be  due  to  affections  of  the  blood  or  dis- 
ease of  the  bloodvessels.  They  occur  in  the  course  of  blood  diseases, 
because  such  change  in  the  quality  of  the  blood  takes  place  that  permits 
diapedesis  more  readily.  They  are  more  particularly,  but  not  exclu- 
sively, seen  in  dependent  parts,  especially  in  the  lower  extremities. 

Significance.  While  subcutaneous  hemorrhages  are  easily  recognized, 
their  diagnostic  significance  is  more  difficult  to  determine  and  must 
depend  upon  the  phenomena  with  which  they  are  associated.  More- 
over, the  situation  of  the  hemorrhage  is  in  a  measure  an  index  of  its 


76  GENERAL  DIAGNOSIS. 

causal  origin;  thus  hemorrhages  about  joints  are  usually  purpuric  or 
hemophilic. 

1.  Hemorrhage  with  Fever.  Subcutaneous  hemorrhages  in  the  course 
of  acute  disease  with  high  temperature  are  due  to  changes  in  the 
quality  of  the  blood,  or  obstruction  of  the  bloodvessels  with  emboli. 
To  the  former  class  belong  cerebrospinal  fever,  and  measles,  variola, 
and  scarlatina.  In  the  exanthemata  they  precede,  develop  with,  or 
even  replace  the  characteristic  eruption,  the  latter  being  darker 
in  color  than  normal.  Hemorrhages  will  probably  take  place  at 
the  same  time  from  the  mucous  membranes;  perhaps  the  nares  will 
be  occluded,  and  the  mouth  and  fauces  filled  with  clotted  blood. 
In  milder  degree  only  sordes  collect  in  the  mouth.  They  indicate  the 
degree  of  malignancy  of  these  affections.  To  the  same  class  of  affec- 
tions belong  epidemic  hozmoglobinuria  and  morbus  maculosus  neona- 
torum, diseases  of  newborn  infants,  but  little  understoood,  although 
no  doubt  of  an  infectious  nature.  To  these  may  be  added  the  severe 
forms  of  purpura  hemorrhagica,  attended  by  fever,  marked  visceral 
disturbances,  skin  eruptions,  and  great  oedema. 

Hemorrhages  due  to  obstruction  of  the  vessels  are  known  as  hemor- 
rhagic infarcts  and  are  seen  in  pyaemia  and  ulcerative  endocarditis. 
The  hemorrhages  are  small,  sometimes  elevated,  more  abundant  on  the 
extremities,  but  distributed  over  the  trunk;  they  are  seen  as  small 
areas  in  the  mucous  membranes,  observed  in  the  conjunctivae,  and,  on 
ophthalmoscopic  examination,  in  the  retina.  The  association  of  chill, 
fever,  and  sweeat,  the  presence  of  pus  in  some  structures  of  the  body, 
and  the  characteristic  joint -affections,  point  to  pyaemia.  On  the  other 
hand,  if  due  to  ulcerative  endocarditis,  the  physical  signs  of  this  affec- 
tion render  the  recognition  of  the  cause  of  the  hemorrhage  clear. 
Finally,  in  fever  with  involvement  of  the  joints,  of  rheumatic,  in 
contradistinction  to  pyaeniic,  origin  we  have  the  occurrence  of  purpura. 
In  the  most  marked  degree  it  is  seen  as  peliosis  rheumatica,  and  is 
associated  with  hemorrhages  in  other  portions  of  the  body. 

2.  Hemorrhage  with  Ancemia.  Hemorrhages  occur  in  all  forms  of 
anosmia  attended  by  debility.  In  idiopathic  or  pernicious  anaemia  they 
are  usually  small,  but  may  become  extensive.  They  occur  on  the 
extremities,  and,  usually,  on  the  dorsum  of  the  feet  or  hands.  There 
may  also  be  retinal  hemorrhages.  They  are  also  seen  in  the  secondary 
anaemias  that  arise  in  the  later  stages  of  tuberculosis  and  of  carcinoma, 
particularly  of  the  stomach;  in  the  later  stages  of  Bright' s  disease, 
and  of  cirrhosis  of  the  liver.  Subcutaneous  hemorrhages  occur  in 
multiple  sarcoma  of  the  skin  and  bones. 

Scurvy  is  an  affection  characterized  by  anaemia,  debility,  and  wasting, 
in  which  there  are  hemorrhages  under  the  skin  as  well  as  from  the 
mucous  surfaces.  The  gums  are  particularly  affected.  They  bleed 
easily.  Hemorrhages  also  occur  in  the  deep  lymphatic  spaces,  in  the 
muscles,  underneath  the  periosteum,'  and  in  the  joints.  In  scurvy- 
rickets  similar  hemorrhages  are  seen. 

3.  Purpura  Rheumatica  (arthritic  pturpura).  In  this  affection  the 
hemorrhages  are  limited  to  the  arms  and  legs,  particularly  about  the 
joints  ;   they  are  comparatively  large,  and  appear  like  black-and-blue 


THE  DATA  OBTAINED  BY  OBSERVATION.  77 

spots  ranging  from  the  size  of  a  three-cent  piece  to  a  half-dollar;  there 
is  a  history  of  rheumatism,  or  the  patient  complains  of  joint-symptoms. 

4.  Haemophilia.  The  diagnostic  significance  of  subcutaneous  hem- 
orrhage is  clearer  when  associated  with  profuse  hemorrhages  in  other 
portions  of  the  body,  and  when  there  is  also  a  history  of  the  occurrence 
of  such  hemorrhages  in  the  family.  The  peculiar  disease,  hcemophiliay 
is  attended  by  hemorrhages  without  cause,  and  with  the  peculiarity  that 
in  certain  families,  for  successive  generations,  bleeders  belonging  to 
the  male  sex  have  been  found,  the  disease  being  transmitted  through 
the  female  members  of  the  family. 

5.  Hemorrhage  in  Central  Nervous  Disease.  Neuritis.  Purpura  in 
some  instances  is  believed  by  Mitchell  to  be  due  to  primary  disease  of  the 
nervous  system  ;  certainly  we  do  see  it  in  neuritis,  in  Raynaud' s  disease, 
in  myelitis,  and  in  locomotor  ataxia.  It  may  occur  in  hysteria,  when,  at 
the  same  time,  drops  of  blood  ooze  through  the  skin  (Hsematidrosis). 

6.  Subcutaneous  Hemorrhage  of  Toxic  Orgin.  The  virus  of  snakes 
causes  hemorrhages  under  the  skin.  In  jaundice  the  blood  is  disin- 
tegrated and  hemorrhages  take  place.  In  malignant  types  the  mucous 
membrane  bleeds  and  sordes  collect  on  the  tongue,  lips,  and  gums.  To 
the  same  class  belong  the  subcutaneous  hemorrhages  that  lollow  the 
administration  of  certain  drugs,  as  copaiba,  iodide  of  potassium,  qui- 
nine, and  belladonna.     (See  Medicinal  Rashes.) 

Eruptions.  Diseases  of  the  skin  are  usually  characterized  by  erup- 
tions. Now,  such  eruptions  may  be  primary  and  local  (from  causes 
operating  directly  on  the  skin)  in  the  sense  that  they  occur  indepen- 
dently of  any  internal  affection;  or  secondary,  the  resultant  of  an 
internal  morbid  process.  The  morbid  processes  are  the  same,  and 
morbid  processes  in  the  skin  do  not  differ  from  such  processes  in 
other  epithelial  structures.  The  anatomical  and  physiological  pecu- 
liarity of  the  part  causes  the  difference  in  the  phenomena.  Hence 
ansemias  and  hyperemias,  inflammations,  acute  or  chronic,  with  or 
without  exudation;  hemorrhages,  atrophies,  and  hypertrophies,  new 
growths,  and  parasitic  affections  are  found  in  both.  But  instead  of  a 
painless  inflammation  with  transudation  of  mucus,  as  in  mucous- 
membrane  inflammation,  we  have  a  more  or  less  painful  inflammation,, 
with  itching  (nerve-supply),  and  with  sebaceous  and  sudoriferous  gland 
exudation.  Otherwise  the  same  symptoms  attend  each;  but  ocular 
examination  of  the  inner  mucous  membranes  is  not  possible. 

While  the  reader  is  referred  to  special  works  on  skin  diseases  for 
a  description  of  the  primary  or  local  skin  affections,  the  secondary 
affections  will  be  briefly  noted.  It  must  not  be  forgotten  that  the  local 
affections — eczemas,  parasitic  disease,  etc.  — are  modified  by  the  general 
conditions  or  state  of  health  of  the  patient. 

Clinical  Significance.  This  depends,  first,  upon  the  special  character 
of  the  eruption,  the  nature  of  the  lesion;  second,  its  distribution — (a) 
in  the  layers  of  the  skin,  (6)  over  the  surface  of  the  body;  third,  its 
association  with  other  morbid  phenomena  or  various  circumstances. 

I.  The  nature  of  the  lesion.  Observation  concerning  the  nature  of 
the  lesion  includes  (1)  its  anatomical  character,  (2)  the  order  of  appear- 
ance, (3)  its  uniformity,  and  (4)  the  mode  of  invasion. 


78  GENERAL  DIAGNOSIS. 

A  knowledge  of  anatomical  lesions  is  essential  in  order  to  be  able 
to  define  exactly  the  morbid  process  and  determine  the  primary  cause 
of  the  lesion.  For  a  long  period  of  time  the  lesions  were  divided 
into  primary  and  secondary.  The  lesions  known  as  scab,  scales,  raw 
surfaces,  scratch-marks,  and  ulcers,  are  always  secondary.  Scars 
and  maculae  appear  latest.  The  other  lesions  herein  described  are 
primary. 

The  writer  follows  Dr.  Pye-Smith  in  the  description  of  them,  as 
well  as  in  most  of  the  matter  appertaining  to  cutaneous  affections. 

1.  Hypercemia,  or  congestion. 

a.  Mere  over  fulness  of  the  vessels  from  paralysis  of  the  vasomotor 
nerves,  with  redness  and  heat,  but  without  the  exudation  and  tissue- 
changes  which  accompany  inflammation.  This  hypereeniic  blush,  readily 
produced  in  the  physiological  laboratory,  is  rarely  seen  as  an  uncom- 
plicated morbid  condition  (e.g.,  Trousseau's  tache  cerebrate). 

b.  Active,  arterial,  or  inflammatory  hypercemia,  varying  in  color  from 
brilliant  scarlet  to  rose-pink,  and  combined  with  heat,  tingling,  or 
other  sensations. 

c.  Passive,  venous,  or  congestive  hypercemia,  dependent  upon  retarded 
circulation  and  distended  venules.  The  color  is  purple,  bluish,  or  livid, 
the  surface  is  cold,  and  there  are  no  painful  sensations. 

2.  Pimple  or  papule.     A  small,  solid  elevation  of  the  skin. 

a.  The  acute  inflammatory  papule. 

b.  The  chronic  large  inflammatory  papule,  discrete  or  confluent. 

c.  A  solid  non-inflammatory  papule. 

cl.   Solid  elevations  of  the  skin,  which  may  be  called  false  papules. 

3.  Vesicle.  A  visible  cavity  in  the  skin  filled  with  transparent 
liquid. 

4.  Pustule.     A  cutaneous  abscess. 

5.  Bulla,  or  bleb.     A  very  large  vesicle. 

6.  Scab,  or  crust.  A  dried-up  concretion  of  the  contents  of  a  vesicle, 
pustule,  or  bleb. 

7.  Scale  (squama).     A  dry  flake  of  epidermic  cells. 

8.  Wheal  (pomphos).  A  flat,  solid  elevation  of  the  skin,  much  larger 
than  a  papule,  and  of  ephemeral  duration. 

9.  Scratch-mark.  An  injury  to  the  skin,  of  linear  form  and  curved 
outline. 

10.  Paw.     A  surface  which  has  lost  its  horny  layer  of  epidermis. 

11.  Chap  (rima).  A  crack  or  fissure  which  goes  through  the  epi- 
dermis. 

12.  Sore  (ulcus).  The  result  of  destruction  by  inflammation,  which 
has  reached  below  the  Malpighian  layer  and  has  destroyed  the  papillae. 

13.  Scar  (cicatrix).  The  result  of  the  healing  process  after  an  injury 
or  disease  deep  enough  to  destroy  the  papillae  of  the  part. 

14.  Nodule.  A  solid  elevation  of  the  skin  larger  than  a  papule, 
and  seated  in  its  deep  layer. 

15.  Stain  (macula).     A  patch  of  increased  pigmentation  of  the  skin. 

16.  Hemorrhage  (ecchymosis).  When  a  bloodvessel  of  the  cutis  vera 
gives  way,  a  dark-red  or  purple  mark  is  produced,  which  (like  the 
macula)  does  not  disappear  on  pressure. 


THE  DATA   OBTAINED  BY  OBSERVATION.  79 

The  recognition  of  the  exact  anatomical  lesion  is  not  sufficient  for 
diagnosis,  unless  the  mode  of  invasion  is  observed  at  the  same  time. 
The  rash  often  spreads  from  a  single  focus,  or  numerous  foci  appear 
and  coalesce.  The  lesion  is  best  studied  in  the  most  recent  part.  Xot 
only  is  the  mode  of  local  invasion  to  be  noted,  but  also  the  uniformity 
of  the  anatomical  lesion.  Often,  instead  of  a  simple  lesion,  various 
kinds  are  present  at  the  same  time,  or  they  develop  in  successive  order; 
thus,  in  smallpox,  we  have  first  the  papule,  then  the  vesicle,  and  finally 
the  pustule. 

II.  Distribution.  The  location  of  the  lesion  in  the  various  layers 
of  the  skin,  and  the  distribution  over  the  surface  of  the  body,  must  be 
observed.  The  layers  of  skin:  (1)  The  horny  layer  of  the  epidermis 
manifests  the  pathological  changes  of  hypertrophy,  atrophy,  dryness, 
or  desquamation  of  the  cuticle.  Dead  scales  result,  in  addition  to  the 
hypertrophies  and  atrophies  indicated  in  the  outline.  (2)  The  eruption 
in  a  large  number  of  cases  is  limited  to  the  living  Malpighian  layer  of 
the  epidermis  and  to  the  papillary  layer  of  the  cutis.  The  hyperemias 
(erythemata),  and  inflammations  of  all  kinds,  are  confined  to  these 
layers.  In  this  situation  they  never  leave  scars.  (3)  The  deep 
layer  of  the  cutis  is  so  intimately  connected  with  the  subcutaneous 
tissue  that  morbid  changes  in  it  involve  the  latter,  and  even  extend 
more  deeply.  The  affections  are  more  severe,  but  less  numerous  than 
affections  of  the  superficial  layers,  and  are  always  followed  by  cica- 
trices. The  changes  in  the  sweat  glands,  sebaceous  glands,  hair  and 
nails,  so  far  as  they  refer  to  internal  medicine,  have  been  treated  in 
another  section. 

Area  of  distribution  :  The  distribution  of  the  eruption  over  different 
areas  of  the  body  is  of  great  importance  in  the  diagnosis  of  the  various 
erythemata  due  to  exanthems,  and  to  morbid  conditions  of  the  gastro- 
intestinal tract.  It  will  be  noted  more  in  detail  when  the  specific  erup- 
tions are  considered.  The  student  should  also  bear  in  mind  the  rela- 
tionship of  eruptions  or  cutaneous  changes  of  nutrition  (trophic  disorders) 
to  the  affected  nerve-supplies. 

III.  Associate  Morbid  Phenomena.  The  student  of  internal  medicine 
should  particularly  observe  the  associated  morbid  phenomena,  or  con- 
comitant circumstances,  in  order  to  determine  the  nature  of  the  skin 
affection,  which  may  be  the  expression  of  internal  disorder.  The  associ- 
ated morbid  phenomena  of  diagnostic  significance  are  fever,  jaundice, 
albuminuria,  and  the  phenomena  of  past  or  present  syphilitic  disease, 
tuberculosis,  rheumatism,  or  the  rheumatic  habit.  The  presence  of  one 
of  these  processes  or  diseases  points  to  particular  affections.  Thus,  a 
large  number  of  eruptions  is  attended  with  fever;  another  group 
is  of  frecment  occurrence  in  the  course  of  rheumatism;  another  class 
belongs  to  syphilis,  while  a  fourth  class  is  associated  with  anaemia, 
jaundice,  or  albuminuria.  This  subdivision  is  not  based  on  the  nature 
of  the  eruption,  but  on  its  association  with  other  phenomena.  It  will 
be  learned  later  that  all  the  groups  belong  to  the  hemorrhar/es  or  the 
erythemata.  The  true  relation-hip  of  the  two  classes  of  phenomena 
can  be  fully  ascertained  only  by  inquiry  into  the  history  and  course  of 
the  eruption  and,  in  addition,  into  the  concomitant  phenomena.    Thus, 


gO  GENERAL  DIAGNOSIS. 

if  the  eruption  is  thought  to  be  due  to  the  exanthemata,  the  period  of 
incubation,  mode  of  infection,  symptoms  of  the  invasion,  and  the  pro- 
gress of  the  attack  must  be  inquired  into. 

General  Symptoms.  In  order  to  determine  accurately  the  cause  of  an 
eruption  and  appreciate  its  diagnostic  significance,  the  general  health 
must  be  inquired  into,  the  condition  of  the  stomach  and  bowels,  and 
the  character  of  the  urine  must  be  ascertained.  It  must  be  remembered 
that  local  skin  disorders  are  influenced,  for  good  or  ill,  by  the  general 
health.  Functional  disorders  of  the  stomach  and  bowels  are  a  frequent 
source  of  many  of  the  erythemas,  while  in  diabetes  pruritus  and  forms 
of  dermatitis  are  of  common  occurrence.  -The  latter  are  also,  observed 
in  Bright' s  disease.  The  cause  lor  the  eruption  is  the  same  in  both, 
in  all  probability — that  is,  a  perverted  secretion  of  the  skin,  or,  if 
oedema  is  present,  impaired  nutrition  of  the  surface. 

The  subjective  symptoms  are  of  great  importance  in  the  attempt  to 
ascertain  the  true  nature  of  an  eruption.  Pain,  itching,  burning, 
smarting,  and  tenderness  are  significant  of  the  inflammations.  Pain 
due  to  inflammation  is  constant  and  smarting,  burning  or  throbbing  in 
character.  Sometimes,  however,  pains  of  a  neuralgic  character,  inter- 
mittent and  distributed  in  the  course  of  nerve-trunks,  precede  the 
development  of  eruption.  This  is  seen  in  herpes  zoster.  Itching  is  an 
important  symptom  in  disease  of  the  skin.  It  is  not  present  in  the 
eruption  due  to  the  exanthemata  generally,  except  in  smallpox,  chicken- 
pox,  and  rubella.  Its  absence  is  a  striking  peculiarity  of  the  eruptions 
of  syphilis  ;  but  in  erythema,  especially  if  associated  with  cedema,  it 
is  a  most  annoying  symptom.  In  other  skin  diseases,  as  eczema,  psori- 
asis, and  the  parasitic  affections,  it  is  much  more  common  and  of 
extreme  annoyance. 

Itching  may  be  present  without  any  anatomical  evidence  of  skin 
disease.  It  is  seen  in  the  troublesome  pruritus  that  occurs  in  the  aged, 
particularly  about  the  intestinal  and  gen ito-uri nary  orifices,  symptom- 
atic of  affections  of  the  organs  related  thereto.  It  is  a  symptom  which 
should  lead  to  an  examination  of  the  urine,  as  diabetes  is  sometimes 
found  to  be  the  fundamental  source  of  the  complaint.  It  has  been 
peviously  noted  that  itching  occurs  to  a  high  degree  in  jaundice.  It  is 
also  due  to  the  internal  administration  of  drugs,  as  opium  and  mor- 
phine, and  sometimes  quinine. 

In  addition  to  the  associate  pathological  phenomena  which  should  be 
ascertained  in  the  study  of  skin  eruptions,  in  order  to  determine  their 
relationship  to  internal  affections,  other  circumstances  should  be  in- 
quired into,  such  as  the  occupation,  the  character  of  the  clothing,  degree 
of  cleanliness  of  the  patient  ;  the  effects  of  climate,  the  season,  tem- 
perature, and  the  state  of  the  air. 

The  following  very  concise  outline,  taken  from  the  work  of  the  above- 
named  author,  to  whom  the  writer  is  indebted  for  much  of  the  data  of 
this  section,  is  here  given  to  enable  the'student  to  appreciate  more  thor- 
oughly the  pathological  relations  of  the  various  skin  diseases.  The 
table  also  shows  at  once  the  relation  of  the  eruptions  to  the  internal 
disorders  which  concern  us  more  particularly  in  this  work  : 


THE  DATA   OUT  A  IS  ED  BY  OBSERVATION.  81 

Diseases  of  the  Skin  Regarded  as  Physiological  Processes. 
(Pathological  Arrangement.) 

Acute  Inflammations. — Diffuse,  e.  g.,  scarlatina,  morbilli,  syphilis,  roseola 
(eruptive  fevers ;  erythema). 

With  venous  congestion — Erythema  nodosum  (rheumatism). 

With  oedema — Urticaria,  erythema  nodosum  (gastro-intestinal  disorder  and 
rheumatism). 

With  necrosis — Furunculus,  anthrax  (diabetes). 

Localized  in  papules — Enterica  (erythemata),  syphilis,  eczema,  prurigo. 

Localized  in  vesicles — Eczema,  zona,  variola,  scabies,  herpes,  varicella  (erup- 
tive fevers,  infectious  diseases). 

Localized  in  pustules — Impetigo,  variola,  scabies,  syphilis,  sycosis,  acne. 

Localized  in  blebs — Pemphigus,  scabies,  rupia. 

Desquamating  during  involution — Scarlatina,  etc. 

Chronic  Inflammations. — With  venous  congestion — Acne  rosacea,  pernio. 

With  over-production  of  epidermis — Psoriasis,  pityriasis  rubra. 

With  oedema — Elephantiasis. 

With  fatty  degeneration — Xanthelasma. 

With  hypertrophy — Elephantiasis. 

With  cicatrization — Cheloid. 

With  ulceration — Lupus,  syphilis,  lepra. 

New  growths — Xanthelasma,  lupus,  lepra,  syphilis,  cancer. 

Atrophy — The  senile  skin,  linese  gravidarum. 

Hypertrophy — Ichthyosis,  cornu  cutaneum,  clavis,  verruca. 

Hemorrhage — Traumatic  (e.  g.,  flea-bites),  typhus,  scurvy. 

Pigmentation — Syphilitic  maculae,  melasma,  chloasma,  icterus,  ephelis. 

Congenital  malformations — Ichthyosis,  cutaneous  nsevus. 

Neurosis — Pruritus  (diabetes,  jaundice). 

Anomalies  of  Secretion. — Increased,  diminished,  or  perverted — Seborrhoea, 
xeroderma,  hyperidrosis,  anidro3is,  chromidrosis,  etc.  Obstructed — Comedo, 
milium,  acne;  sudamina. 

A  glance  at  the  above  outline  will  show  that  the  eruptions  which 
particularly  concern  us  belong  to  the  class  of  diseases  to  which  the 
term  erythema  is  applied. 

Erythema.  Classification.  Erythemata  may  be  divided,  in  accord- 
ance with  the  classification  of  Kaposi,  into  acute,  contagious,  exudative 
dermatoses,  represented  by  measles,  scarlatina,  rubella,  and  smallpox; 
and  the  acute,  non-contagious,  inflammatory  dermatoses,  which  may  be 
further  subdivided  into  :  (1)  typical  fornix,  idiopathic  and  toxic,  includ- 
ing urticaria,  or  nettle-rash;  (2)  varieties  of  herpes;  (3)  erythemas  due 
to  boils,  colds,  or  erysipelas.  The  first  group  of  the  non-contagious 
form  includes  the.  class  which  should  always  be  considered  in  connection 
with  the  diagnosis  of  fevers.  The  skin  inflammations  closely  simulate 
in  their  symptoms  the  eruptive  fevers,  even  to  the  affections  of  the 
mucous  membranes.  Besnier  has  named  them  the  pseudo-exanthems, 
and  divides  them  into  rubeloids  and  scarlatinoids.  Both  simulate  erup- 
tive fevers  throughout  their  course,  and  hence  both  are  acute  and  febrile. 
The  scarlatiniform  erythemas  are  febrile  at  the  beginning,  subacute  in 
course,  but  of  longer  duration  than  the  fever  they  simulate.  They  are 
the  most  common  forms,  and  arise  from  infectious  diseases,  such  as 
puerperal  fever,  septicaemia,  and  gonorrhoea,  or  from  toxsernia  due  to 
drugs  or  articles  of  food. 

Character  of  eruption  in  the  non-contagious  forms.  The  erythemata 
are  characterized  by  (a)  rose  rash  with  injection  of  the  surface,  either 

6 


82  GENERAL  DIAGNOSIS. 

(6)  with  general  oedema,  or  with  circumscribed  local  oedema,  forming 
wheals,  or  with  papules.  In  rare  cases  bullae  are  also  formed,  (c)  The 
rash  is  followed  by  a  branny  desquamation,  (d)  The  exudation  that 
attends  the  lesion  is  always  watery,  in  contradistinction  to  the  sero- 
purulent  or  purulent  exudation  of  eczema  and  scabies.  Sometimes 
slight  hemorrhages  attend  the  lesion,  as  in  cases  of  purpura  or  of  urti- 
caria, (e)  The  course  of  the  erythema  is  of  diagnostic  significance. 
It  begins  quickly  and  is  usually  attended  with  febrile  symptoms,  some- 
times mild,  again  very  intense.  (/)  The  duration  is  short;  at  least  it 
is  not  indefinite.  The  erythemas  that  are  recurrent  must  not  be  consid- 
ered to  be  one  process  of  long  duration.  (g)  The  locality  of  the  ery- 
thema is  not  of  precise  diagnostic  significance.  The  eruption  is  usually 
symmetrical,  and  the  favorite  localities  may  be  defined  as  the  extensor 
surfaces  of  the  forearms  and  leg,  the  face,  cheeks,  neck,  and  the  chest 
and  abdomen.  True  erythema  does  not  attack  the  scalp,  the  flexures  of 
the  joints,  the  palms  (except  erythema  multiforme),  nor  the  soles. 
(h)  The  local  symptoms  that  attend  erythemata  are  mild.  Local  ten- 
derness is  more  marked  than  in  eczema.  Smarting  and  tingling  are 
complained  of,  but  severe  pain  and  excessive  itching  are  rare.  Only 
when  wheals  are  present  do  we  find  pruritus.  The  rash  of  erythema 
does  not  spread.  Patches  occasionally  unite,  but  an  atfected  area  never 
enlarges  its  borders. 

The  oetiology  of  erythema  is  involved  in  obscurity.  Although  the 
frequent  associate  phenomena  are  not  of  setiological,  they  are  certainly 
of  diagnostic  significance.  We  may  have  them  occur  under  the  follow- 
ing circumstances  :  1 .  In  one  class  the  eruption  is  symptomatic,  depend- 
ing upon  dyspepsia  or  upon  rheumatic  fever.  2.  In  the  eruptive  fevers, 
especially  scarlatina  and  measles,  in  enteric  fever  and  cholera,  and  in 
syphilis,  there  is  an  early  erythema  preceding  the  later  true  eruption. 
3.  The  most  striking  instance  of  the  relationship  to  internal  disorder 
is  seen  in  the  rash  that  arises  after  the  administration  of  medicine,  as 
copaiba,  or  after  the  taking  of  certain  foods.  4.  The  erythemata  occur 
most  commonly  in  children  and  young  people.  They  are  very  frequent 
in  men.  The  age  at  which  they  occur  coincides  with  that  of  rheuma- 
tism. 

Varieties  of  non-contagious  erythemata  :  First,  erythema  multiforme 
in  simple  form,  with  papules  or  Avith  exudation;  it  may  disappear  in  a 
few  hours,  or  persist  for  a  day  or  two  and  form  rings  (erythema  fur/ax 
and  erythema  annulatum).  With  the  fading  of  the  redness  faint  desqua- 
mation ensues,  and  there  may  be  a  few  pigment-marks.  The  annular 
form  is  observed  in  rheumatic  fever.  In  addition  to  rheumatism  eryth- 
ema multiforme  may  be  found  associated  with  the  following  affections  : 
Typhoid  fever,  puerperal  fever,  gonorrhoea,  cholera,  infectious  endocar- 
ditis and  osteomyelitis,  syphilis,  leprosy,  vaccination,  and  surgical 
septicaemia. 

Et^ythema  lave  often  appears  upon  the  tense  skin  of  dropsical  parts. 
It  may  be  the  result  of  acupuncture. 

Vesicular  and  bullous  erythema.  To  this  class  belong  the  affections 
known  as  herpes  and  erythema  bullosum.  Herpes  zoster  is  observed 
in  the  cutaneous  distribution  of  one  or  more  nerves.     It  consists  of 


THE  DATA  OBTAINED  BY  OBSERVATION.  83 

vesicles  of  flattened  form,  ranged  in  clusters  of  twenty  or  thirty,  lying 
on  a  reddened,  slightly  swollen  bed  of  skin.  The  number  of  clusters 
varies  from  one  to  ten.  The  vesicles  develop  in  quick  succession, 
beginning  usually  near  the  roots  of  the  nerve  whose  branches  they  fol- 
low. A  short  papular  stage  precedes  the  vesicles,  and  some  of  the 
vesicles  abort.  The  eruption  tends  to  dry  up  in  five  or  six  days.  The 
crusts  form  in  yellowish  or  brownish  clusters,  which  fall  off  in  the 
third  week,  leaving  purple  stains. 

When  the  disease  attacks  the  face  it  follows  the  course  of  the  fifth 
nerve.  The  several  twigs  of  the  trifacial  are  traced  out  from  their 
points  of  emergence  from  the  bony  canals.  Great  swelling  of  the  eye- 
lids sometimes  takes  place  on  "account  of  the  loose  tissue,  so  that  ,the 
lesion  may  be  mistaken  for  erysipelas.  Ulceration  of  the  cornea  and 
iris  sometimes  occurs,  and,  when  lower  divisions  of  the  trifacial  are 
affected,  vesicles  may  appear  in  the  mucous  membrane  of  the  mouth 
and  palate.  The  cervical  nerves  and  those  of  the  upper  extremity  are 
also  affected  in  their  distribution.  The  eruption  on  the  arm  rarely 
goes  below  the  elbow.  When  the  second  and  third  intercostal  nerves 
are  affected  the  intercosto-humeral  branch  produces  an  eruption  down 
the  inner  side  of  the  arm.  The  eruption  occurs  frequently  on  the 
trunk.  Following  the  course  of  the  dorsal  nerves,  it  slants  downward 
as  it  approaches  the  pubes. 

In  the  distribution  of  the  disease  in  the  lower  limbs  the  eruption 
rarely  extends  below  the  knee  or  buttocks.  It  follows  the  course  of 
the  external  cutaneous  or  anterior  crural  nerves,  or  that  of  the  small 
sciatic.  Some  of  the  branches  of  the  sacral  nerves  are  also  affected. 
The  disease  is  unilateral,  and  its  precise  limitation  to  one-half  of  the 
body  is  of  the  greatest  diagnostic  significance. 

While  fever  or  general  symptoms  do  not  usually  attend  its  course  in 
any  marked  degree,  insomnia  and  depression  are  likely  to  occur,  prob- 
ably on  account  of  the  severe  neuralgic  pain.  Pain  is  the  most  impor- 
tant subjective  symptom.  It  is  localized  in  the  nerves  in  the  distribution 
of  which  the  eruption  takes  place.  It  is  not  so  likely  to  be  present  in 
the  young.  The  pain  may  precede  the  eruption  by  several  days,  and 
persist  long  after  the  eruption  subsides.  This  is  particularly  the  case 
in  old  people. 

Herpes  labialis,  or  facialis,  consists  of  vesicles  arranged  in  groups 
or  clusters  upon  an  inflamed  surface.  They  appear  very  suddenly  upon 
the  upper  lip  or  the  alse  of  the  nose,  sometimes  on  the  cheek  or  chin, 
and  they  may  appear  inside  the  mouth.  They  undergo  some  changes, 
as  in  herpes  zoster,  but  are  not  attended  by  severe  neuralgic  pain. 
They  are  always  symptomatic  of  an  internal  disorder,  an  acute  catarrh 
(cold),  or  follow  a  rigor,  as  in  intermittent  fever  or  pneumonia.  Thev 
may  be  present  in  epidemic  cerebro-spinal  meningitis,  but  are  never 
present  in  tuberculous  meningitis.  Diagnosis  of  the  former  disease  is 
confirmed  by  their  presence.  (Klemperer.)  Herpes  iris  and  herpes 
prieputialis  have  no  diagnostic  significance  of  internal  disease. 

Erythema  nodosum.  With  the  erythema  there  is  great  oedema.  The 
spots  are  somewhat  painful  and  tender,  but  do  not  itch.  The  redness 
of  the  erythema  is  modified  by  the  hue  of  venous  congestion.      Small 


84  GENERAL  DIAGNOSIS. 

hemorrhages  may  be  seen.  The  patches  develop  ou  the  legs,  their 
long  diameter  being  parallel  to  the  tibia.  They  rise  slowly  into  hard 
masses.  They  may  be  seen  on  the  ankles  or  the  calf,  and  sometimes 
on  the  ulna.  They  occur  frequently  in  those  who  have  suffered  from 
rheumatic  fever. 

Urticaria  is  a  form  of  erythema  in  which  wheals,  sometimes  sur- 
rounded by  an  erythematous  blush,  are  seen.  It  is  an  acute  inflamma- 
tory oedema  of  the  cutis.  The  serous  exudation  fills  the  lymph-spaces 
and  expels  blood  from  the  venules.  It  takes  place  suddenly,  and  may 
be  excited  by  chemical  irritation  or  a  mechanical  irritant,  as  the  finger 
drawn  across  the  skin.  Small  patches,  or  large  white  areas,  are  seen, 
due  to  the  coalescence  of  smaller  ones  (giant  urticaria).  All  parts  of 
the  body  may  be  affected,  except  the  scalp,  face,  and  soles  of  the  feet. 
The  eruption  is  not  symmetrical.  Its  course  may  be  acute,  or  it  may 
be  chronic  and  transitory,  characterized  by  successive  attacks.  It  is 
the  form  of  erythema  in  which  intense  itching  is  the  most  pronounced 
symptom.  There  are  no  other  subjective  symptoms.  The  itching 
causes  restlessness  and  loss  of  sleep.  '  Urticaria  is  symptomatic  of  gas- 
tric or  intestinal  disturbance,  or  the  ingestion  of  drugs  or  poisous. 
Another  form  follows  the  tapping  of  a  hydatid  cyst.  It  occurs  some- 
times in  women  at  each  menstrual  period,  and  may  be  traced  to  ovarian 
disorder.  It  may  occur  after  severe  shock  to  the  nervous  system,  with 
high  fever.  It  is  not  an  infrequent  complication  of  rheumatic  fever. 
It  occurs  in  men  and  women  equally,  but  is  most  frequent  in  children 
and  adolescents. 

Medicinal  Rashes.  To  the  erythemata  belong  most  of  the  so- 
called  medicinal  rashes. 

The  following  drugs  are  known  to  cause  erythema:  potassium  bromide 
and  iodide,  copaiba,  cubebs,  the  essential  oils,  capsicum,  santonin, 
chloral,  opium,  morphine,  antipyrin,  salicylic  acid  and  its  compounds, 
iodoform,  belladonna  and  atropine,  tar,  carbolic  acid,  arsenic,  cannabis 
indica,  digitalis,  mercury,  silver,  and  copper. 

Belladonna  produces  in  susceptible  persons,  or  when  administered  in 
poisonous  doses,  a  diffuse,  bright-red  erythema,  closely  resembling  that 
of  scarlet  fever,  but  without  the  darker  red  points  which  interrupt  the 
latter.  Atropine  also  produces  in  some  persons,  especially  on  the  shoul- 
ders, arms,  chest,  and  face,  an  eruption  of  disseminated,  small,  hard 
vesico-papules,  showing  no  tendency  to  pustulation.  They  are  seated 
on  an  inflammatory  base,  but  are  more  superficial  than  acne. 

The  bromides  produce  a  characteristic  pustular  eruption  which  is  most 
intense  upon  the  shoulders,  face,  chest,  and  arms.  Large  doses  or  long- 
continued  administration  is  generally  required  to  bring  it  out.  It  is 
conspicuous  upon  the  face  of  some  epileptics. 

The  iodides  produce  an  eruption  which  is  not  often  pustular,  but  an 
erythematous  or  papular  rash  is  not  uncommon.  It  appears  chiefly 
about  the  forearms,  face,  and  neck.  Vesicles,  bulla?,  and  purpuric 
spots  are  also  occasionally  seen. 

The  eruption  produced  by  quinine  is  generally  erythematous,  and  is 
attended  with  itching  and  burning;  the  face  and  neck  are  attacked  first. 

Opium  and   its  alkaloid   also   produce,   in    susceptible  persons,   an 


THE  DATA  OBTAINED  BY  OBSERVATION.  85 

erythematous  scarlatinoid  eruption  which  is  accompanied  by  intense 
itching.  Itching,  especially  about  the  nose,  is  much  more  common 
without  eruption. 

Copaiba  produces  a  vesico-papular  or  papular  eruption  which  resem- 
bles urticaria  and  erythema  multiforme.  It  is  itchy.  It  is  more  apt  to 
be  seen  on  the  extremities.      It  may  be  purpuric. 

The  eruption  of  cubebs  is  a  diffused  erythema,  with  millet-sized  pap- 
ules, coalescent  here  and  there.  Unlike  the  eruption  of  copaiba,  it  is 
more  copious  over  the  face  and  trunk  than  over  the  extremities 

Antipyrin  causes  a  measles-like  or  urticaria-like  eruption. 

Erythemata  of  Infectious  Diseases.  The  inflammations  of  the 
skin  which  are  symptomatic  of  a  specific  infection  are  also  of  an  ery- 
thematous variety.  The  term  exanthemata  has  been  applied  to  the  latter, 
but  the  eruptions  of  typhus  and  typhoid  (enterica)  belong  to  the  same 
class.  The  characteristics  and  distinctions  of  the  various  forms  will  be 
described  in  sections  devoted  to  the  respective  diseases.  The  student 
should  remember  the  association  with  the  general  phenomena,  particu- 
larly fever,  the  onset  and  the  course  of  which  should  be  carefully 
observed. 

Roseola.  To  add  to  the  confusion,  an  erythema  called  roseola  often 
precedes  the  eruption  of  a  particular  fever.  The  association  with 
this  class  of  fevers  has  been  indicated  before.  Roseola  is  of  a  deep  rose- 
color,  not  arranged  in  crescent ic  patches,  as  in  measles,  nor  scarlet  and 
capable  of  being  resolved  into  innumerable  red  points,  as  in  scarlatina. 
It  is  not  so  diffuse  as  the  latter.  It  precedes  smallpox,  scarlatina, 
measles,  cholera,  typhoid  fever,  syphilis,  diphtheria,  and  malaria.  In 
smallpox,  in  cases  of  cholera,  and  after  parturition  and  surgical  opera- 
tions, the  rash  is  copious,  but  is  characterized  by  being  seated  over  the 
lower  half  of  the  abdomen  and  the  anterior  and  inner  aspects  of  the 
thighs.  It  may  appear  elsewhere,  but  is  usually  confined  to  that  por- 
tion of  the  body.  The  erythema  of  roseola  maybe  mistaken  for  rubella, 
measles,  or  scarlatina.  The  following  are  points  of  distinction  :  First, 
it  is  neither  contagious  nor  epidemic;  second,  there  are  no  prodromal 
symptoms;  third,  the  rash  does  not  come  out  after  a  definite  period  of 
fever;  fourth,  it  is  not  confined  to  any  special  locality;  fifth,  the  fever 
is  of  short  duration  and  moderate  degree,  rarely  above  101°;  sixth, 
there  is  no  catarrhal  discharge  from  the  eyes  or  nose,  or  in  the  pharynx; 
the  fauces  and  palate  are  reddened,  without  swelling;  seventh,  it  is  not 
seen  in  the  mouth,  like  the  eruptions  of  measles  or  scarlatina;  eighth, 
if  present,  the  fever  which  precedes  the  eruption  is  of  only  a  few 
hours'  duration  (in  scarlatina  it  lasts  twenty-four  hours,  in  measles 
seventy-two  hours);  ninth,  the  rash  is  not  crescentic  as  in  measles,  nor 
punctiform  as  in  scarlatina,  though  it  must  be  admitted  that  severe  cases 
of  the  affection  cannot  be  easily  diagnosticated,  the  development  of  the 
sequelre  alone  concluding  the  diagnosis. 

Sufficient  reference  has  been  made  to  the  erythemata  that  attend 
rheumatism.  A  few  other  internal  (infectious)  disorders  are  associated 
with  the  development  of  an  eruption.  In  cholera,  during  the  period 
of  reaction,  a  rose  rash  which  may  resemble  erythema,   urticaria,  or 


86  GENERAL  DIAGNOSIS. 

scarlatina  appears  coincidently  with  a  rise  of  temperature.  It  is  most 
frequently  seen  on  the  forearms  and  backs  of  the  hands,  but  may  cover 
the  back  and  limbs.  It  may  be  slightly  hemorrhagic  and  last  two  or 
three  days.  A  slight  desquamation  usually  follows.  In  influenza  a 
roseolous  eruption,  covering  the  trunk  and  limbs  and  becoming  papular, 
is  seen  in  rare  cases. 

In  addition,  erythematous  eruptions  are  sometimes  seen  in  the  course 
of  BrigMs  disease.  Two  forms,  quite  distinct  from  the  previously 
mentioned  erythema  laeve,  are  observed  :  the  roseola  on  the  feet,  legs, 
and  hands — rarely  on  the  chest  and  abdomen;  and  the  papular  form 
on  the  thighs,  arms,  and  shoulders.  Itching  and  other  subjective  symp- 
toms do  not  attend  the  eruption.  A  form  with  desquamation  may  begin 
on  the  limbs.  These  erythemata  are  common  in  the  later  stages  of 
Bright' s  disease,  but  are  not  of  ill  omen.  In  acute  Bright' s  disease  a 
transient  roseola  is  observed  very  rarely;  so  also  is  purpura.  If  there 
is  much  anasarca  in  tubal  nephritis,  erythema  is  more  common.  The 
eruptions  usually  appear  independently  of  ursernic  symptoms,  and  disap- 
pear during  their  continuance.  They  are  in. all  probability  allied  with 
the  inflammation  which  attacks  the  lungs  and  serous  membranes  in 
Bright' s  disease. 

Sudamina.  Here  may  be  mentioned  another  eruption,  or  condition 
of  skin,  common  in  the  course  of  internal  diseases.  Sudamina  or 
miliaria  are  small,  clear  vesicles  seen  in  large  numbers,  usually  on  the 
abdomen,  but  also  on  any  other  part  which  reflects  the  light  strongly. 
They  are  seen  during  and  after  the  subsidence  of  profuse  sweats. 
While  actual  perspiration  is  seen  on  the  forehead,  the  trunk  may  ap- 
pear free  from  moisture.  When  the  hand  is  placed  over  it,  as  on  the 
abdomen,  the  dryness  is  noted,  but  at  the  same  time  a  roughened, 
nutmeg-grater-like  sensation  is  felt.  On  close  inspection  this  is  observed 
to  be  due  to  the  eruption  just  mentioned.  The  vesicles  are  usually  of 
good  prognostic  omen  in  the  course  of  febrile  diseases,  particularly 
typhoid  fever.  They  are  due  to  the  accumulation  of  perspiration  under 
the  epidermis. 


General  Diagnosis,  of  Skin  Affections. 
{Condensed  from  Pye-Smith.) 

I.  Factitious  Eruptions.  We  must  never  forget  the  possibility 
of  the  affection  before  us  being  artificial.  All  kinds  of  dermatites, 
eczema,  erysipelas,  pemphigus,  impetigo,  may  be  simulated  by  the 
application  of  various  irritants.  Pigmentation  also  has  often  been 
imitated  with  success.  Such  artificial  lesions  will  generally  be  found 
upon  the  arms,  rarely  on  the  face,  and  scarcely  ever  beyond  reach  of 
the  patient's  hands.  Mustard,  cantharides,  and  some  other  irritants 
can  be  distinguished  with  the  aid  of  the  microscope. 

II.  Traumatic  Eruptions.  In  all  cases  of  dermatitis  we  should 
seek  for  the  irritant,  and  sometimes  it  is  so  directly  the  cause  of  the 
disease  that  the  eczema  or  impetigo  in  question  may  be  considered  purely 


THE  DATA  OBTAINED  BY  OBSERVATION.  87 

traumatic,  and  efficient  treatment  immediately  follows  accurate  diag- 
nosis :  sublata  causa  tollitur  effectus. 

Pediculi  in  the  hair  should  be  carefully  looked  for  in  all  cases  of 
impetigo  in  children,  pediculi  vestimentorum  in  prurigo  of  old  people. 
The  acarus  of  scabies,  fleas,  bugs,  and  gnats,  should  be  looked  for. 
In  adults,  pediculi  pubis  may  sometimes  be  found  in  the  axillae  as  well 
as  in  their  proper  region,  and  when  they  have  been  destroyed  by  mer- 
curial ointment  the  patient  is  at  once  relieved  from  pruritus. 

Frequently  the  irritant  must  be  sought  in  the  objects  which  the  patient 
habitually  handles.  The  coarser  kinds  of  brown  sugar  are  a  frequent 
cause  of  eczema  of  the  hands  (grocer's  itch).  So  with  many  of  the 
"  chemicals"  used  in  a  variety  of  modern  handicrafts.  Constant 
washing  of  the  hands  in  washerwomen,  in  scrubbers,  in  potmen,  and 
many  others,  produces  eczema  runosum.  The  heat  of  the  sun  is  the 
cause  of  eczema  solare  and  ephelides;  the  heat  of  the  fire,  of  the  pig- 
ment-spots on  the  shins  of  elderly  people.  Sweat,  again,  is  a  very  com- 
mon irritant,  producing  the  erythema  which  usually  accompanies  suda- 
niina  and  also  intertrigo  of  opposed  surfaces.  Scratching,  as  a  cause  of 
traumatic  dermatitis,  has  been  repeatedly  referred  to. 

III.  Febrile  Rashes.  We  must  never  forget  that  a  cutaneous 
eruption  may  possibly  be  part  of  an  acute  exanthem.  The  use  of  a 
clinical  thermometer  is  a  great  help  in  this  respect.  Variola  is  fre- 
quently mistaken  for  syphilis  and  other  affections. 

TV.  Medicinal  Rashes.  Other  cases  are  due  to  certain  kinds  of 
food,  or  to  drugs.     They  have  been  described  above. 

V.  Syphilodermata.  When  we  have  satisfied  ourselves  that  the 
eruption  before  us  is  not  factitious,  nor  directly  traumatic,  nor  a  symp- 
tomatic eruption,  we  may  next  consider  whether  or  not  it  is  due  to 
syphilis.  In  this  inquiry  it  is  undesirable  to  ask  questions  the  answers 
to  which  are  as  apt  to  mislead  as  to  guide  aright. 

1.  We  should  first  consider  the  color  of  the  affected  skin,  remember- 
ing, however,  that  the  pigmentation  which  gives  the  so-called  coppery 
or  raw-ham  tint  to  a  syphilitic  eruption  is  the  same  which  is  sooner  or 
later  produced  by  all  forms  of  dermatitis.  Psoriasis,  chronic  eczema, 
lichen  planus,  and  prurigo  may  all  produce  shades  which  bear  the 
closest  resemblance  to  syphiloderma. 

2.  The  lesions  of  syphilis  are  multiform.  It  is  rare  in  any  but 
syphilitic  affections  to  find  mere  hypersemia  in  one  part,  and  associated 
pustules,  papules,  scales,  or  ulcers  in  others;  and  it  is  not  often  that 
a  syphilitic  eruption  exhibits  only  a  single  elementary  lesion. 

A  pustular  eruption  in  an  adult  should  always  suggest  the  question 
of  syphilis,  when  that  of  scabies  has  been  answered  in  the  negative. 

3.  Syphilitic  eruptions,  for  some  unknown  reason,  do  not  itch — the 
exceptions  to  this  rule  are  remarkably  few;  they  usually  occur  during 
tin'  -tage  of  scabbing  of  pustular  rashes,  or  during  the  healing  of  ter- 
tiary ulcers.  An  ordinary  secondary  syphilidc  may,  however,  as  a 
rare  exception,  be  so  irritating  that  wheals  and  scratch-marks  are  pres- 
ent. On  the  other  hand,  psoriasis  is  often  free  from  irritation,  while 
the  degree  of  itching  of  eczema,  and  even  of  scabies  and  prurigo, 
varies  greatly. 


88  GENERAL  DIAGNOSIS. 

4.  The  local  distribution  of  syphilitic  disease  is  a  great  aid  in  diag- 
nosis. Specific  eruptions  are  certainly  not,  as  a  rule,  symmetrical;  the 
early  roseolous  rash  is  only  so  because  it  is  general,  and  therefore,  upon 
a  surface  like  the  human  body,  more  or  less  symmetrical.  Moreover, 
as  it  chiefly  affects  the  face,  chest,  and  trunk  generally,  it  is  near  the 
middle  line.  But  we  do  not  see  symmetrical  patches  of  syphilide  in 
corresponding  parts  of  both  sides  of  the  face,  both  sides  of  the  trunk, 
or  the  right  and  left  limbs.  In  all  but  the  earliest  syphilides  the  affected 
patches  are  very  decidedly  and  constantly  unsymmetrical,  irregularly 
scattered  over  head,  trunk  and  limbs,  and  chiefly  remarkable  for  having 
no  well-marked  seats  of  predilection. 

The  forehead,  especially  about  the  roots  of  the  hair,  is,  however,  very 
frequently  the  seat  both  of  the  early  and  middle  erythematous,  scaly, 
and  pustular  syphilides,  and  the  palms  of  the  hands  and  soles  of  the 
feet  are  frequently  symmetrically  affected  with  the  later  scaly  eruption. 

Practically,  when  we  find  a  disease  of  the  skin  occupying  some  un- 
usual position  we  should  at  least  consider  the  question  of  syphilitic 
origin. 

5.  These  signs,  alone  or  in  combination,  serve  to  distinguish  early 
specific  roseola  from  erythema,  eczema,  scarlatina,  and  measles,  and  the 
later  eruptions  from  eczema,  lichen,  impetigo,  and  psoriasis. 

The  eruptions  of  congenital  syphilis  which  are  most  liable  to  be  mis- 
taken are  :  The  so-called  pemphigus  of  infants,  which  is  known  by  its 
affecting  the  palms  and  soles;  rupia,  which,  by  the  form  of  the  crusts 
and  the  ulcerated  surface  beneath,  may  always  be  distinguished  from 
impetigo;  an  erythematous  rash  of  the  nates  and  genitals  of  infants, 
which  is  distinguished  from  eczema  of  the  same  parts,  also  common  at 
that  age,  by  its  coppery  color,  its  blotchy  distribution,  and  more  clearly 
defined  margin. 

The  tertiary  ulcers  of  syphilis  are  distinguished  by  their  presence  in 
unusual  places,  by  their  punched-out  edges,  circular  or  so-called  horse- 
shoe shape,  and  by  the  fact  that  they  usually  give  little  pain  or  dis- 
comfort. 

Tertiary  ulcers  have  no  predilection  for  the  outer  side  of  the  leg,  but, 
inasmuch  as  the  part  above  the  inner  malleolus  is,  from  anatomical 
causes,  the  chosen  seat  of  varicose  ulcers,  most  ulcers  in  the  first  position 
will  be  syphilitic,  and  in  the  latter  not.  Moreover,  the  age  helps  in 
the  diagnosis,  as  varicose  ulcers  rarely  occur  before  the  fortieth  year. 
Most  ulcers  on  the  arms  are  found  to  be  tertiary  syphilitic  ulcers. 

VI.  Tineae.  The  next  group  of  skin  diseases  includes  those  which 
are  due  to  vegetable  parasites — tinea  versicolor  of  the  trunk,  eczema 
marginatum  of  the  perineum  and  thighs,  tinea  circinata  of  the  neck 
and  other  parts,  tinea  sycosis  of  the  chin,  and  tinea  tonsurans  of  the 
scalp.      In  all  doubtful  cases  the  microscope  should  be  employed. 

Tinea  of  the  scalp  is  rare  in  adults,  and  tinea  circinata  still  more  so; 
tinea  marginata  occurs  only  in  adult  males. 

VII.  Primary  Superficial  Inflammations.  To  distinguish  the 
superficial  from  the  deeper  kinds  of  dermatitis,  we  should  notice  whether 
the  cutis  alone  is  infiltrated  and  thickened,  or  whether  it  is  bound  down 
by  adhesions  to  the  subcutaneous   tissues.     The   presence  of  scars, 


THE  DATA   OBTAINED  BY  OBSERVATION.  89 

however  slight,  is  a  proof  that  the  process  has  gone  deeper  than  the 
papilla?,  and  has  more  or  less  extensively  destroyed  the  papillary  layer. 
Superficial  inflammations,  excluding  those  due  to  acarus,  to  pediculi, 
and  to  other  direct  irritants,  and  excluding  also  those  which  are  the 
result  of  vegetable  parasites  and  of  syphilis,  fall,  with  respect  to  their 
treatment,  into  three  large  groups  : 

The  first  group,  represented  by  impetigo  and  most  forms  of  eczema, 
consists  of  inflammations  which  are  subacute,  and  accompanied  with 
burning,  itching,  and  pain,  sometimes  with  a  slight  degree  of  fever. 

The  second  group  of  superficial  inflammations  of  the  skin  is  typically 
represented  by  psoriasis,  but  includes  lichen  planus,  the  more  chronic, 
dry,  and  obstinate  forms  of  eczema,  and  true  prurigo.  These  affec- 
tions are  chronic,  with  little  irritation,  exudation,  pain,  or  active  signs. 

The  third  group  is  that  of  erythemata. 

VIII.  The  Acne  Group.  Acne,  both  in  its  pathology  and  etiol- 
ogy, differs  from  other  forms  of  dermatitis.  The  age  of  the  patient 
and  its  distribution  are  sufficient  for  diagnosis.  It  is  at  once  a  super- 
ficial and  a  deep  dermatitis,  and  is  often  followed  by  scars.  Its  treat- 
ment consists  entirely,  or  almost  entirely,  in  local  applications  directed 
to  the  correction  of  the  sebaceous  affection.  With  acne  may  be  classed 
sycosis  and  furunculus. 

IX.  Deep  Affections.  When  we  have  ascertained  that  the  affection 
of  the  skin  is  deep,  that  is  to  say,  that  it  goes  below  the  papillary  layer, 
the  field  of  diagnosis  is  limited. 

Excluding  erysipelas,  which  is  distinguished  by  its  acute  character 
and  febrile  symptoms,  excluding  the  pustular  affections  which  affect 
the  skin  deeply  and  produce  scars  only  at  isolated  points,  such  as  acne, 
variola,  and  herpes  zoster,  and  excluding,  thirdly,  leprosy  and  other  ex- 
otic diseases,  we  have  to  distinguish  in  the  great  majority  of  cases  which 
come  before  us  in  this  country — first,  traumatic  and  varicose  ulcers; 
second,  gummata  and  syphilitic  ulcers;  third,  lupus;  fourth,  rodent 
ulcer  ;  and  fifth,  carcinoma  of  the  skin. 

With  regard  to  the  first  of  these,  we  must  not  assume,  because  a  sore 
upon  the  skin  is  said  to  be  the  result  of  a  blow  or  a  kick,  that  it  is 
purely  traumatic,  for  syphilitic  ulcers  often  arise  in  this  way.  Malig- 
nant ulcers  are  rare,  and  are  usually  obvious  from  the  age  of  the 
patient,  the  pain  they  occasion,  their  tumid  margins,  and  their  blood- 
stained secretions.  Moreover,  they  are,  with  few  exceptions,  confined 
to  the  neighborhood  of  the  orifices  of  the  body,  especially  the  lower 
lip,  the  urethra,  the  vulva,  and  the  anus.  Rodent  ulcer,  however,  is 
very  difficult  to  diagnose  with  certainty.  Its  locality,  its  slow  and 
painless  progress,  and  its  belonging  to  the  latter  half  of  life,  usually 
serve  to  distinguish  it  from  lupus;  and  its  being  single,  excessively 
chronic,  and  unaccompanied  by  nodes  or  other  syphilitic  lesions,  are 
the  best  characteristics  for  diagnosis  from  a  tertiary  ulcer. 

Palpation.  The  Nutrition  of  the  Skin.  The  color,  as  deter- 
mined by  inspection,  is  a  fair  index  of  the  nutrition  of  the  skin,  but 
further  information  is  obtained  by  palpation.  In  health  the  skin  is 
smooth,  firm,  and  elastic.  When  pinched  between  the  thumb  and 
fingers  and  then  allowed  to  escape,  it  slips  quickly  back  into  its  former 


90  GENERAL  DIAGNOSIS.     ' 

position.  When  pressed  or  squeezed,  it  becomes  pale  from  expression 
of  blood,  but  resumes  its  natural  hue  immediately. 

The  readiness  with  which  the  blood  returns  after  pressure  shows  the 
character  of  the  capillary  circulation  of  the  skin.  This  is  active  in 
health,  aud  sluggish  in  serious  disease  of  the  lungs,  heart,  and  blood- 
vessels. In  the  eruptive  fevers,  especially  in  measles,  scarlet  fever, 
and  smallpox,  sluggish  capillary  circulation  with  dusky  eruption  is  a 
grave  sign.  la  measles  it  is  usually  due  to  pulmonary  complications, 
and  in  other  infectious  diseases  to  the  overwhelming  effects  of  the  poison. 

As  age  advances  the  skin  becomes  less  elastic,  and  in  old  persons 
may  lie  in  wrinkles.  When  pinched  between  the  fingers  the  skin  is 
more  inclined  to  remain  wrinkled.  Fat  persons  whose  skin  is  firm  and 
hard  are  in  much  better  condition  than  those  whose  skin  is  loose  and 
flabby.  The  latter  condition  is  frequently  met  with  in  babies,  particu- 
larly those  that  are  fed  on  artificial  foods.  When  the  skin  is  thin  and 
dry  and  loses  its  tone,  so  that,  when  pinched  into  fokls,  it  resumes  its 
smoothness  but  slowly  and  sluggishly,  it  is  usually  evidence,  in  a  per- 
son under  fifty,  of  some  grave  cachexia,  as  carcinoma. 

Moisture  and  Dryness  of  the  Skin.  Moisture  and  dryness 
are  in  one  sense  correlated  with  the  nutrition  of  the  skin.  It  is  quite 
certain  that  when  the  skin  is  abnormally  dry  its  nutrition  is  impaired. 

In  health  the  skin  is  not  perceptibly  moist,  except  as  the  result  of 
physical  exertion  or  under  heat,  or  as  the  immediate  result  of  imbibing 
a  hot  fluid  or  a  sudorific  drug.  There  is  considerable  individual  differ- 
ence, however,  within  the  limits  of  the  normal.  Rheumatic  and  stru- 
mous persons  may  have  a  perceptibly  moist  and  oily  skin  at  all  times, 
while  others  have  a  skin  which  perspires  very  little,  even  under  influ- 
ences which  usually  bring  about  perspiration. 

Perspiration  Increased.  The  term  hyperidrosis  is  applied  to  this 
condition.      It  may  be  general  or  local. 

A.  General  Increased  Perspiration  is  seen — 1.  With  elevated  tem- 
perature. It  occurs  in  the  course  of  rheumatism,  when  the  sweats  are 
strong  in  odor  and  acid  in  reaction.  It  is  seen  in  tuberculosis,  especially 
the  miliary  variety.  It  is  sometimes  marked  throughout  cases  of 
typhoid  fever.  General  perspiration  also  attends  the  violent  muscular 
action  of  tetanus,  but  is  not  seen  in  epilepsy.  An  example  of  general 
sweating  is  seen  in  that  curious  affection  to  which  the  term  "  sweating 
sickness"  has  been  applied.  It  is  a  fever  the  nature  of  which  is  not 
well  known,  but  in  which  this  symptom  is  most  pronounced.  Sweating 
is  extreme  in  trichinosis. 

2.  With  normal  or  subnormal  temperature,  a.  Sudden,  temporary 
perspiration.  Sweats  occur  from  excitement  or  slight  exertion  in 
patients  during  convalescence.  A  general  profuse  perspiration  may  be 
of  short  duration  and  occur  suddenly  after  fright  or  shock  in  health. 
It  is  the  characteristic  perspiration  of  collapse.  The  forehead  is  cov- 
ered with  sweat,  large  drops  stand  out  on  the  face,  the  hands  and  feet 
are  moist  or  wet  with  perspiration,  and  the  whole  surface  of  the  body 
"  leaks."  It  is  attended  by  a  cold  and  clammy  skin.  In  the  col- 
lapse of  all  forms  of  shock,  or  after  hemorrhage  or  profuse  discharge, 
as  in  cholera,  this  form  of  perspiration  is  seen. 


THE  DATA  OBTAINED  BY  OBSERVATION.  91 

More  striking  still  are  the  perspirations  that  suddenly  break  out  in 
the  course  of  acute  disease  coincidently  with  a  fall  of  temperature.  We 
have  (1)  the  critical  sweats  of  pneumonia  and  relapsing  fever;  (2)  sweats 
which  terminate  a  paroxysm  of  intermitting  fever,  whether  of  malarial 
or  infectious  origin  (see  Fever);  (3)  the  profuse  perspiration  that 
attends  pyaemia,  breaking  out  with  each  fall  of  temperature  to  disap- 
pear as  it  rises;  (4)  the  night-sweats  that  attend  tuberculosis  and  other 
exhausting  diseases.  In  tuberculosis  and  in  pus-formation  or  accumu- 
lation the  oscillation  of  temperature,  with  or  without  chills,  followed 
by  sweating,  is  known  as  hectic.  Sudden  breaking  out  of  perspira- 
tion general,  but  more  notably  seen  on  the  face,  attends  dyspnoea  of 
pulmonary  origin  and  the  attacks  of  dyspnoea  in  the  course  of  organic 
heart  disease.  These  perspirations  are  at  times  the  result  of  an  effort 
at  elimination,  on  the  part  of  the  skin,  to  relieve  the  kidneys  or 
bowels,  such  as  the  perspiration  of  urcemia,  which  is  attended  by  a 
urinous  odor.  At  times  it  may  also  occur  in  jaundice.  In  the  condi- 
tions just  mentioned  there  are  coolness  of  the  skin  and  cold  extremities. 

b.  Prolonged  Perspiration.  In  exhausting  diseases  general,  persis- 
tent perspiration  may  occur,  particularly  in  the  later  stages,  as  in  tuber- 
culosis, and  in  any  disease  attended  by  persistent  dyspnoea. 

B.  Local  increased  perspiration  (hyperidrosis  localis)  occurs  when 
there  is  local  vasomotor  paresis.  Thus,  in  organic  diseases  of  the  brain 
and  in  affections  of  the  peripheral  nerves,  in  some  forms  of  neuralgia, 
in  migraine  and  in  hysteria,  it  has  been  observed.  Sometimes  one  side 
of  the  body  alone  is  affected,  even  in  a  malarial  paroxysm  (hemidrosis). 

Local  sweats  are  sometimes  significant.  This  is  the  case  particularly 
with  a  sweat  confined  to  the  head,  which  occurs  usually  in  children, 
and  is  one  of  the  striking  characteristics  of  rickets.  With  the  local 
sweating  the  patient  rolls  his  head  at  night  from  discomfort.  The  hair 
on  the  back  of  the  head  is  rubbed  off. 

Unilateral  sweating  of  the  head  may  arise  from  destructive  pressure 
on  the  sympathetic  nerves,  causing  paralysis  of  the  dilator  fibres  of 
the  cilio-spinal  branches ;  in  thoracic  aneurism,  and  in  caries  of  the 
lower  cervical  vertebrae.  There  are  usually  contraction  of  the  pupil 
and  congestion  of  the  face  on  the  same  side. 

Diminished  Perspiration — Anidrosis.  The  skin  is  abnormally  dry 
in  the  early  stages  of  acute  disease  attended  by  fever,  particularly  if 
the  febrile  rise  takes  place  suddenly,  as  in  acute  digestive  disorders  of 
children.  In  adults,  when  the  disease  is  accompanied  by  high  fever, 
as  in  thermic  fever,  the  skin  is  dry.  In  the  first  day  of  the  eruption 
of  the  exanthemata  the  dryness  is  marked.  Dryness  of  the  skin  is  of 
frequent  occurrence  when  there  are  copious  discharges  of  water  from 
the  bowels  or  the  kidneys.  In  choleraic  diarrhoea  the  dryness  occurs 
suddenly.  In  some  affections,  as  diabetes  and  Bright' s  disease,  the 
dryness  extends  over  a  long  period  of  time,  and  is  frequently  attended  by 
eruptions  or  desquamations  and  by  the  formation  of  boils.  When  there 
are  accumulations  of  serum  in  the  lymph-spaces  of  the  subcutaneous 
connective  tissue,  or  changes  in  the  connective  tissue,  as  in  dystrophies 
or  myxcedema,  or  scleroderma,  the  skin  is  dry  because  of  the  stretching 
and  pressure  on  the  bloodvessels. 


92  GENERAL  DIAGNOSIS. 

Scars.  Scars  are  important  proofs  of  the  occurrence  of  previous 
disease,  especially  smallpox,  chickenpox,  and  syphilis.  Scars  of  the 
first  two  occur  in  the  form  of  circular  pits,  and  almost  always  on  the 
face.  Scars  of  syphilis  are  larger,  circular  or  oval  in  shape,  and  seen 
usually  to  the  best  advantage  on  the  extremities,  but  the  single  scar  on 
the  forehead  is  strikingly  suggestive.  Scars  upon  the  legs  in  persons 
under  thirty  years  of  age,  when  not  traumatic,  are  almost  always  syph- 
ilitic. Scars  as  the  result  of  suppurating  glands  are  seen  most  fre- 
quently in  the  neck,  but  may  be  found  wherever  there  are  glands, 
especially  under  the  jaw  and  in  the  axilla  and  groin.  They  are  most 
liable  to  occur  in  tuberculous  persons,  either  spontaneously  or  as  the 
result  of  the  exanthemata,  erysipelas,  or  other  infectious  disease. 
When  such  scars  are  met  with  in  a  person  with  incipient  tuberculosis 
the  prognosis  becomes  more  anxious. 

The  appearance  of  the  scar  indicates  its  age  in  a  general  way,  and 
hence  throws  light  upon  the  patient's  previous  history,  and  also  serves 
as  a  check  upon  the  accuracy  of  his  statements. 

Scars  the  result  of  wounds,  injuries,  or  operations  may  be  seen  any- 
where; they  are  of  importance  only  so  far  as  they  may  furnish  a  clue 
to  the  cause  of  existing  disease.  Of  such  nature  are  the  scars  upon 
the  head  in  cases  of  brain  disease,  particularly  epilepsy. 

The  scars  of  pregnancy,  the  striae  seen  upon  the  lower  part  of  the 
abdomen  and  the  upper  part  of  the  thigh,  must  not  be  confounded  with 
similar  scars  that  occur  in  great  oedema,  and  which  are  sometimes 
found  in  fat  persons.     They  are  also  seen  after  typhoid  fever. 

Enlargements  or  Swelling's.  The  subeutaneous  connective  tissue. 
Swelling  of  the  surface  is  an  indication  of  change  in  this  tissue. 
(Edema,  my x  oedema,  subcutaneous  emphysema,  dystrophies,  sclero- 
derma, brawny  induration,  and  local  subcutaneous  swellings  are  the 
principal  ones  to  be  considered. 

CEdema  ;  Dropsy.  The  lymph-spaces  of  the  subcutaneous  connec- 
tive tissue  become  overdistended  with  serum,  causing  an  accumulation 
to  which  the  general  term  dropsy  is  applied.  If  the  accumulation  is 
local  and  confined  to  small  areas,  it  is  known  as  oedema.  If  it  is  gen- 
eral, and  if,  in  addition,  the  large  lymph-cavities,  the  pleura,  the  peri- 
toneum, and  the  pericardium  contain  fluid,  it  is  known  as  anasarca. 
Accumulation  occurs  because  more  fluid  is  poured  out  by  the  vessels 
than  can  be  removed  by  the  lymphatics  and  veins.  This  may  depend 
either  upon  obstruction  of  the  veins  and  lymphatics,  or  excessive  exu- 
dation Jroin  the  bloodvessels,  or  both.  The  former  condition,  however, 
is  rare,  and  usually  local,  because,  unless  the  obstruction. is  very  great, 
the  veins  and  lymphatics  are  able  to  carry  away  more  fluid  than  is 
effused  from  the  capillaries. 

1.  Excess  of  fluid  transudes  when  there  is  local  capillary  change  from 
inflammation  or  the  effects  of  poisons.  The  change  must  be  in  the 
capillaries.  It  was  thought  that  this  general  process  was  of  an  inflam- 
matory nature,  but  at  present  it  is  believed  to  be  due  to  the  influence 
of  poisons,  probably  absorbed  from  the  intestinal  canal,  altering  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  93 

nutrition  of  the  capillary  vessels.  Thus,  the  oedema  and  general  dropsy 
of  albuminuria,  particularly  in  the  early  stage  of  that  affection,  are 
thought  to  be  due  to  a  poison  circulating  in  the  blood,  which  also  causes 
the  nephritis.  Mahomed  found  a  pre-albuminuric  stage  of  scarlet 
fever,  in  which  he  noted  a  peculiar  reaction  of  the  urine,  which  gave  a 
blue  color  with  guaiac.  A  brisk  purgative  administered  when  this 
reaction  was  noticed  would  prevent  the  occurrence  of  albuminuria; 
whereas,  if  the  drug  was  withheld,  albuminuria  always  followed.  The 
purgative  removed  the  poison  which  caused  the  nephritis  and  oedema. 

It  is  well  known  that  in  urticaria  there  is  marked  local  oedema. 
Brunton  thinks  that  some  poisons  circulating  in  the  blood  cause  paral- 
ysis of  the  secreting  power  of  the  sweat-glands,  on  account  of  which 
there  is  not  only  effusion  from  the  bloodvessels,  but  at  the  same  time 
such  changes  in  the  secreting-cells  take  place  as  to  produce  an  acid,  the 
local  irritative  action  of  which,  upon  the  capillaries,  causes  a  further 
transudation  of  fluid.  That  acids  circulating  in  the  blood  have  the 
power  of  creating  oedema,  the  experiments  of  Cash  and  Brunton  fully 
demonstrate.  While,  therefore,  in  the  oedema  of  Bright' s  disease  in 
its  earliest  stage,  and  in  urticaria,  we  have  this  explanation  of  the 
phenomena,  other  factors  are  causal  in  other  forms  of  oedema. 

2.  Increased  transudation  and  obstruction  to  the  flow  of  lymph  are 
the  causes  of  some  forms  of  oedema.  It  may  be  of  local  origin,  as  in 
the  oedema  over  the  site  of  an  inflammation  or  the  oedema  of  an  arm 
or  leg  from  venous  occlusion,  or  it  may  be  of  general  origin,  as  in 
cardiac  disease.  The  obstruction  may  be  in  the  lymphatics  or  in  the 
veins.  In  the  former  it  may  occur  (a)  from  want  of  muscular  action  ; 
(6)  from  want  of  inspiratory  action  of  the  thorax;  (c)  diminution  of  the 
diastolic  suction  of  the  heart;  (d)  positive  pressure  on  the  veins.  In 
the  latter,  obstruction  of  the  veins  is  caused  by  conditions  similar  to 
those  affecting  the  lymphatics,  and  arises  from  (a)  want  of  muscular 
action;  (b)  want  of  movement  of  the  thorax;  and  (<?)  feeble  action  of 
the  heart ;  and,  in  addition,  it  is  likely  to  be  caused  by  (d)  complete 
arrest  of  blood-flow  from  external  pressure  upon  the  vein,  or  irom 
plugging  of  the  vein.  It  can  readily  be  seen,  with  a  little  knowledge 
of  physiology,  how  the  above  factors  favor  the  development  of  oedema, 
due  to  disease  of  the  heart  and  to  venous  obstruction.  The  baneful 
factors  are  those  which  retard  the  flow  of  blood,  preventing  its  return 
to  the  right  heart.     Hence  it  is  called  the  oedema  of  passive  congestion. 

3.  A  third  form  of  oedema,  usually  slight,  is  that  which  is  seen  in 
anaemia.  Several  factors  combine  to  produce  it:  (a)  the  watery  condi- 
tion of  the  blood;  (6)  the  condition  of  the  capillaries;  and  (c)  vaso- 
motor paresis  on  account  of  imperfect  nutrition  of  the  vasomotor  centres. 
It  may  be  diffused,  as  in  the  anascarca  that  attends  the  anaemia  of 
malaria. 

4.  CEdema  may  be  of  nervous  origin.  The  oedema  that  occurs  in 
diseases  or  injuries  of  nerves  belongs  to  this  class.  To  it  possibly 
belongs  the  oedema  of  beri-beri.  It  may  be  a  trophoneurosis  with 
secondary  alterations  in  the  permeability  of  the  vascular  walls.  It 
may  be  due  to  vasomotor  paralysis. 

Mode  of  Recognition.      Whether  the  accumulation  is  in  local 


94  GENERAL  DIAGNOSIS. 

areas  or  distends  the  entire  subcutaneous  tissue,  the  oedema  is  not 
difficult  of  recognition.  The  part  is  swollen  and  puffy,  the  surface 
is  pale,  smooth,  and  shiny,  the  temperature  is  usually  low,  and  the 
affected  area  pits  on  pressure.  Pitting  is  more  pronounced  if  the 
finger  is  pressed  over  a  part  which  is  seated  upon  a  firm  background, 
as  bone.  (Edema  of  the  ankle  or  over  the  tibia  is  more  readily  recog- 
nized than  oedema  in  the  calves. 

The  oedema  obliterates  normal  depressions  and  increases  the  ro- 
tundity of  the  affected  part.  It  causes  deformity,  as  of  the  face  and 
neck,  or  of  the  penis,  when  the  accumulation  of  serum  is  considerable. 
The  swelling  appears  in  the  most  dependent  parts,  if  the  oedema  is 
diffuse  or  the  cause  is  general,  as  in  cardiac  disease;  or  in  parts  made 
up  of  loose  connective  tissue,  as  the  eyelids  or  scrotum.  The  tem- 
porary disappearance  of  the  oedema,  either  entirely,  or  from  one  part, 
to  appear  in  another,  is  a  prominent  feature  of  it.  It  will  disappear 
between  morning  and  evening,  or  its  position  will  alter  with  change  in 
the  position  of  the  body.  The  presence  of  a  previously  existing  oedema 
can  often  be  told  by  the  scars  or  striae  that  resulted  from  overstretching 
of  the  skin,  as  of  the  abdomen  and  thighs. 

(Edema  is  to  be  distinguished  from — (1)  Inflammatory  swellings,  by 
the  absence  of  the  classical  signs  of  inflammation  :  pain,  heat^  and 
redness.  (2)  The  enlargement  of  myxoedema  differs  irorn  oedema  by 
the  absence  of  pitting  on  pressure,  the  occurrence  of  induration,  which 
resists  the  pressure  of  the  finger,  and  by  the  occurrence  of  anaesthesia 
or  analgesia.  (3)  The  swellings  of  connective-tissue  dystrophies  are 
hard,  localized  areas  that  do  not  pit  on  pressure,  and  are  not  seated  in 
dependent  parts  of  the  body.  They  are  found  on  the  arm,  for  instance, 
or  on  the  thigh,  or  about  the  flanks  and  in  the  axillae.  (4)  The  swell- 
ing of  subcutaneous  emphysema  differs  from  oedema,  in  that  it  arises  in 
the  course  of  some  disease  of  the  air-passages,  and,  on  palpation,  the 
crackling  sensation  of  air  under  the  finger  is  distinctly  felt,  while  there 
is  no  pitting  on  pressure.  In  the  cases  that  the  writer  has  seen  the 
parts  were  particularly  tender,  although  pain  in  subcutaneous  em- 
physema is  said  usually  to  be  absent. 

Diagnostic  Significance.  The  value  of  oedema  as  a  diagnostic 
sign  depends  upon  its  location,  its  mode  of  development,  and  its  asso- 
ciation with  disease  of  other  organs  or  structures  of  the  body. 

Location.  The  oedema  may  be  limited  to  small  areas,  as  the  eye- 
lids, the  face,  or  the  feet,  or  to  an  arm  or  leg;  it  may  involve  an  arm 
and  leg  of  the  same  side;  or  it  may  involve  the  extremities  and  trunk 
and  even  include  the  face.   We  therefore  have  local  and  general  oedema. 

Local  (Edema.  Local  oedema  occurs  when  there  is  pressure  on  a 
vein  or  occlusion  of  it  by  a  thrombus.  (Edema  of  the  arm  from  pres- 
sure on  the  veins  by  enlarged  lymphatic  glands  in  the  axilla,  and  oedema 
of  the  leg  from  thrombosis  of  the  femoral  vein,  are  examples  of  this 
form  of  local  oedema.  Dropsy  of  an  arm  often  occurs  when  the  patient 
has  laid  upon  it.  Local  oedema  also  occurs  over  the  seat  of  inflamma- 
tion and  is  a  valuable  diagnostic  sign.  It  is  an  indication  of  suppura- 
tion. It  is  known  as  "inflammatory"  or  "collateral  oedema."  It  is 
due  to  obstruction  of  the  lymph  circulation.    It  is  seen  over  the  mastoid, 


THE  DATA  OBTAINED  BY  OBSERVATION.  95 

when  its  cells  are  the  seat  of  inflammation;  over  the  parotid  gland  under 
the  same  circumstances;  over  parts  of  the  thorax  in  empyema;  over  the 
prsecordia  in  purulent  pericarditis;  over  the  surface  of  the  liver  in  some 
cases  of  hepatic  abscess;  in  the  abdominal  parietes  in  purulent  perito- 
nitis, but  more  marked  over  the  primary  locus  of  inflammation,  as  the 
gall-bladder  region  or  the  region  of  the  appendix. 

The  Arms  and  Thorax.  Another  form  of  local  oedema  occurs  when 
there  is  pressure  upon  the  superior  vena  cava  from  aneurism,  or  dis- 
ease of  the  mediastinal  glands.  The  oedema  is  then  limited  to  the 
arms,  head,  neck,  and  thorax.  Such  oedema  is  usually  associated 
with  cyanosis  of  the  hands  and  arms.  There  is  also  marked  dis- 
tention of  the  veins  of  the  upper  parts  of  the  body.  The  cedema  has 
been  found,  in  a  few  instances,  to  be  more  marked  on  one  side  than  on 
the  other.  This  has  occurred  in  cases  of  aneurism  which  communi- 
cated with  the  vena  cava.  Either  the  collateral  circulation  on  one  side 
had  been  established,  or  pressure  was  greater  on  the  left  innominate 
vein.  The  oedema  is  sometimes  limited  to  the  head  and  arms.  If  the 
obstruction  of  the  superior  cava  is  situated  below  the  entrance  of  the 
azygos  vein,  the  chest  shares  in  the  venous  congestion  and  resulting 
oedema.  If,  on  the  other  hand,  the  obstruction  is  above  the  azygos 
vein,  there  is  no  oedema  of  the  chest- wall.  This  form  of  oedema,  as  a  rule, 
is  easily  recognized  by  the  presence  of  the  above-mentioned  symptoms, 
with  other  pressure-symptoms,  due  to  disease  of  the  mediastinum,  and 
by  the  results  of  physical  examination,  which  reveals  the  presence  of 
a  tumor  in  the  thorax.  It  usually  develops  slowly,  hand-in-hand  with 
the  other  symptoms.  At  times,  however,  it  occurs  suddenly.  Sudden 
oedema  in  this  situation  is  always  due  to  an  aneurism  which  has  rup- 
tured into  the  vena  cava  (see  above).  The  sudden  onset  is  attended  by 
physical  signs  of  aneurism,  or,  if  they  are  not  present,  by  a  murmur 
characteristic  of  the  communication  between  an  artery  and  a  vein.  It 
must  be  confessed  that  often  the  physical  signs  are  not  precise  and  the 
murmur  is  absent.  The  suddenness  of  the  peculiar  localized  oedema  is 
the  chief  point  of  diagnosis  in  favor  of  this  rare  form  of  aneurism. 

The  Oedema  of  Trichinosis  (see  Face).  (Edema  of  the  skin  over  the 
affected  muscles,  as  well  as  of  the  face,  occurs  in  trichinosis.  It  begins 
early  in  the  disease,  disappears  after  a  few  days,  to  return  again  later. 
It  is  localized  in  the  muscles,  and  is  associated  with  the  growth  of 
trichinae  in  them.  It  is  distinguished  from  cardiac  and  renal  dropsy  by 
its  course  and  situation  as  well  as  by  the  fact  that  the  scrotum  and  labia 
majora  are  never  oedematous. 

The  cause  of  the  above  forms  of  oedema  is  local  and  in  close  proximity 
to  or  intimate  anatomical  relation  with  the  dropsical  swelling.  But  the 
cause  of  local  oedema  may  be  central,  or  in  a  sense  general.  It  then 
develops  gradually  and  begins  in  special  localities,  as  in  the  feet  or  face. 

The  Feet.  (Edema  of  the  feet  or  ankles  is  usually  due  to  disturbance 
of  the  circulation.  It  arises  in  heart  disease,  or  in  the  course  of  any 
exhausting  and  debilitating  disease  in  which  the  heart  has  become  weak- 
ened. The  organic  change  which  takes  place  in  the  heart-muscle  (dila- 
tation) in  the  course  of  obstructive  valvular  disease  and  in  lung  disease 
is  often  attended  by  oedema  of  the  feet.     Later  a  general  dropsy  may 


96  GENERAL  DIAGNOSIS. 

ensue.  But  oedema  of  the  feet  may  occur  from  another  cause,  i.  e. , 
anaemia.  In  all  forms  of  this  affection  puffiness  of  the  ankles  may  be 
seen.  An  explanation  of  the  cause  has  been  given.  Similar  localized 
oedema  in  individuals  of  relaxed  fibre  occurs  in  the  evening  after  a 
day  of  considerable  physical  exertion.  (Edema  of  the  feet,  subse- 
quently becoming  diffuse,  occurs  in  beri-beri. 

(Edema  of  the  Face.  (Edema  may  begin  or  remain  localized  in  the 
face,  and  is  very  striking.  (See  Face  and  Eyelids.)  It  may  be  limited 
to  the  eyelids,  as  a  simple  puffiness,  or  may  spread  over  the  entire  face, 
causing  complete  obscuration  of  the  normal  outlines.  It  is  the  oedema 
of  renal  disease,  and  differs  from  oedema  of  the  feet  in  that  it  is  more 
marked  in  the  morning  on  rising  and  disappears  toward  night.  Of  all 
forms  of  local  oedema  it  is  the  most  grave,  and  should  at  once  call  atten- 
tion to  the  condition  of  the  urine,  particularly  if  the  patient  has  just 
had  an  attack  of  scarlatina,  or  if  it  occurs  in  a  woman  who  is  pregnant. 

The  diagnostic  significance  of  primary  local  oedema  may  be  sum- 
marized as  follows:  1,  eyelids  or  eyes  ("  Bright"  eye,  "tear  that  does 
not  fall")  in  nephritis;  2,  face,  nephritis;  3,  forehead,  trichinosis;  4, 
head,  pressure  upon  superior  vena  cava  above  the  azygos  vein;  5,  one 
side  of  head,  pressure  upon  innominate  vein;  6,  head  and  arms,  or 
head,  arms,  and  thorax,  pressure  upon  superior  vena  cava;  7,  one  arm, 
pressure  upon  axillary  veins;  8,  one  leg,  pressure  upon  femoral  vein; 

9,  both  feet  or  legs,  pressure  upon  inferior  vena  cava  by  abdominal 
tumor,  loss  of  vasomotor  tone,  heart  disease,  anaemia,  late  nephritis; 

10,  the  loins,  "lumbar  cushion,"  nephritis,  cardiac  disease  if  patient  is 
in  recumbent  posture;  11,  the  scrotum,  nephritis  and  cardiac  disease; 
12,  local  oedemas  over  inflammations  of  structures  underneath,  as  bones, 
the  gall-bladder,  the  appendix,  the  pleura,  peritoneum  or  pericardium. 

General  (Edema.  (Edema  of  the  face  and  feet  may  become  gen- 
eral. In  cases  in  which  the  face  is  first  cedematous,  its  extension  may 
be  very  rapid,  so  that  twenty-four  to  forty-eight  hours  after  the  swelling 
is  noticed  the  whole  body  is  in  a  state  of  anasarca.  The  extension  of 
oedema,  primarily  seated  in  the  feet  and  legs  (cardiac  dropsy),  through- 
out the  rest  of  the  body  is  more  gradual,  and  develops  with  other  signs 
and  symptoms  of  weakness  of  the  heart.  Hence  cyanosis  gradually 
appears.  This  may  be  seen  first  in  the  extremities.  Finally  the  face 
and  lips  take  on  the  peculiar  hue.  On  the  other  hand,  in  the  general 
anasarca  that  follows  the  local  oedema  of  the  face  in  Bright' s  disease 
pallor  occurs,  and  as  the  cedema  increases  it  becomes  more  and  more 
of  a  waxy  hue,  while  the  extremities  become  glistening  or  shining  in 
appearance. 

Angioneurotic  (Edema.  This  curious  affection  is  not  of  fre- 
quent occurrence.  It  may  be  present  in  the  individuals  of  several 
generations  of  a  family.  The  attack  comes  on  suddenly.  The  swell- 
ing is  circumscribed.  It  may  appear  on  the  face,  on  the  brow,  the  lips 
or  cheek.  The  eyelid  is  a  common  situation.  It  may  also  occur  on 
the  backs  of  the  hands,  the  legs,  or  in  the  throat.  It  remains  but  a 
short  time,  and  disappears  as  quickly  as  it  came  on.  The  outbreaks 
have  exhibited  distinct  periodicity.  Local  symptoms  of  itching,  heat, 
or  redness,  or  general  urticaria  may  precede  the  swelling.     The  sudden 


THE  DA  TA  OB  TA IX ED  B  Y  OB  SEE  VA  TION.  9  7 

swelling  causes  great  deformity.  If  the  upper  lip  is  affected,  the  mouth 
cannot  be  opened;  if  the  hands,  the  fingers  cannot  be  bent.  In  the 
hereditary  cases  the  attack  recurs  every  three  or  four  weeks.  The 
danger  to  life  is  from  oedema  of  the  larynx,  which  caused  death  in  two 
of  Osier's  cases.  The  general  symptoms  that  attend  the  attack  are 
gastro-intestinal.    Nausea  and  vomiting  occur,  followed  by  severe  colic. 

It  must  not  be  confounded  with  simple  urticaria,  or  the  giant  form 
of  that  affection,  with  which  it  may,  however,  have  close  affinities. 
It  is  regarded  by  Quincke  as  a  vasomotor  neurosis,  which  leads  to  im- 
pairment of  the  permeability  of  the  vessels. 

Recapitulation.  From  what  has  been  said,  the  student  will 
observe  that  oedema  may  be  local  or  general;  that  local  oedema  may  be 
unilateral  or  bilateral;  that  oedema  may  be  further  subdivided,  in 
accordance  with  the  cause,  into  inflammatory  dropsy,  oedema  or  dropsy 
of  passive  congestion,  hydrsemic  dropsy,  and  vasomotor  dropsy.  The 
forms  of  passive  dropsies  just  indicated  may  be  subdivided  into  cardiac 
dropsy,  hepatic  dropsy,  and  renal  dropsy,  according  to  anatomical 
causes. 

While  the  account  of  oedema  just  given  refers  more  particularly  to 
the  subcutaneous  accumulation  of  serum,  the  same  pathology  and  aeti- 
ology apply  to  accumulations  in  the  large  lymph-cavities,  and  hence, 
in  addition  to  general  oedema,  we  may  have  ascites,  hydro-pericard'mm, 
hydrothorax,  hydrocele,  and  effusion  in  the  joints.  The  methods  of 
recognition  of  dropsy  of  the  larger  cavities  will  be  deferred  until  dis- 
eases associated  with  these  particular  regions  are  discussed.  It  must 
be  remembered  that  oedema  or  accumulations  of  serum  in  cavities  may 
be  of  local  or  general  origin. 

It  must  not  be  forgotten  that  two  or  more  causes  may  combine  to 
produce  a  dropsy,  or  that  a  dropsy  of  one  cause  may  for  a  time  be 
dependent  upon  a  second  and  even  a  more  pronounced  factor  later  on 
in  the  development  of  the  disease.  Thus  (a)  the  dropsy  of  hydroemia 
may  be  aggravated  by  that  of  (/>)  weak  heart  which  arises  from  anaemia, 
to  which  may  be  added  later  the  dropsy  of  vasomotor  paresis.  The 
dropsy  in  Bright' s  disease  is  due  to  (a)  capillary  changes  produced  by  a 
poison  circulating  in  the  blood,  and  (6),  later,  to  the  condition  of  the 
heart  if,  as  is  frequently  the  case,  it  undergoes  dilatation. 

Myxcedema.  Enlargement  of  the  surface  of  the  body,  local  or 
general,  is  also  seen  in  myxoedema,  a  condition  which  simulates  dropsy, 
as  already  stated.  In  myxoedema  the  swelling  is  general.  The  face 
is  involved.  The  arms  are  more  markedly  swollen,  however,  than 
the  fingers  ;  the  legs  more  than  the  feet.  The  swelling  is  due  to 
the  infiltration  of  mucin  into  the  connective  tissue,  and  arises  from 
some  affection  of  the  thyroid  gland.  The  gland  is  absent,  functionally 
or  actually.  The  hard,  indurated,  non-pitting  swelling  is  associated 
with  striking  change  in  the  appearance  of  the  face,  particularly  the 
nose  and  forehead.  The  nose  becomes  thickened,  the  forehead  more 
prominent  and  overhanging.  The  outline  of  the  face  is  rounded,  so 
that  the  term  "full-moon  "  is  applied  to  it.  The  skin  is  thickened, 
dry,  and  rough,  somewhat  translucent  in  appearance,  pale  or  yellow  in 

7 


98  GENERAL  DIAGNOSIS. 

color,  and  of  a  doughy  consistence,  but  with  a  moderate  degree  of  elas- 
ticity, The  perspiration  is  diminished.  The  hands  change  in  shape,  they 
become  square  or  spade-shaped,  and  the  fingers  clubbed.  The  appen- 
dages of  the  skin  change.  The  nails  become  brittle  and  distorted,  the 
hair  dry,  harsh  and  brittle,  and  it  may  fall  out.  With  these  remarkable 
changes  in  the  exterior,  marked  nervous  and  mental  symptoms  arise. 
Speech  is  thick  and  hesitating,  the  memoiy  feeble.  The  intellect  is 
dull  and  irresponsive,  the  temper  irritable.  Sensibility  is  impaired, 
particularly  the  loss  of  sensation  to  pain.  Patients  have  been  burned 
without  their  knowledge.  This  happened  in  one  of  the  writer's  cases. 
Abnormal  sensations  of  heat  and  chilliness  are  complained  of,  as  well 
as  other  paresthesias.  The  patient  is  anaemic,  the  temperature  is  sub- 
normal, the  heart's  action  weak,  the  respiration  sluggish.  Breathless- 
ness  on  slight  exertion  is  pronounced,  and  exertion  itself  is  very  diffi- 
cult, while  there  is  greater  sense  of  fatigue  than  the  exertion  and  the 
condition  of  the  organs  would  warrant.  The  muscularity  is  enfeebled. 
There  are  impairment  of  appetite,  indigestion,  and  flatulency.  The 
urine  may  become  albuminous,  but  for  a  long. time  is  not  characteristic 
save  in  amount  and  specific  gravity.  The  former  is  increased,  the  latter 
lowered. 

As  the  case  advances,  mental  and  physical  failure  becomes  more  pro- 
nounced, the  patient  is  subject  to  hallucination,  and  is  extremely  irri- 
table. Stupor  sets  in;  death  may  take  place  in  coma,  or  from  uraemia. 
It  is  a  disease  of  mature  life  and  occurs  most  frequently  in  women. 

Subcutaneous  Emphysema.  Enlargement  of  or  swelling  of  the 
surface,  either  local  or  general,  may  occur  on  account  of  air  underneath 
the  skin.  The  skin  is  pale  and  quite  distended,  and  hence  depressions 
are  filled  up,  as  the  axillary,  clavicular,  and  intercostal  spaces.  The 
primary  seat  of  the  swelling  is  in  close  proximity  to  the  ah -passages,  and 
occurs  because  of  communication  between  them  and  the  subcutaneous 
connective  tissue.  It  may  occur  in  ulcerations  of  the  upper  passages, 
as  the  larynx  or  trachea;  in  ulcerations  of  the  oesophagus  into  the  medi- 
astinum; in  the  ulceration  and  rupture  of  phthisical  cavities  into  the 
chest-wall;  and  in  rupture  of  the  lungs,  from  hard  coughing,  sharp 
crying,  severe  exertion  such  as  blowing  of  wind  instruments.  The  air 
may  escape  under  the  pleura  to  the  mediastinum  and  thence  to  the 
neck,  or,  when  the  pleura  is  adherent,  air  will  pass  from  the  lung 
into  the  connective  tissue.  The  swelling  gradually  spreads  over  the 
entire  body  from  the  seat  of  rupture  or  in  close  proximity  to  it.  In 
a  case  of  laryngeal  phthisis  under  the  writer's  care  it  encircled  the 
neck  and  spread  uniformly  over  the  anterior  and  posterior  portion  of 
the  thorax.  Thence  it  extended  downward  until  it  met  a  correspond- 
ing infiltration  of  the  lymph-spaces  in  the  thighs,  due  to  serum.  The 
distinction  between  oedematous  swelling  and  subcutaneous  emphysema 
could  thus  be  made  :  the  latter  offered  no  resistance,  did  not  pit  on 
pressure,  crackled  under  the  finger,  and  was  quite  tender  on  pressure. 
Spontaneous  pain  was  not  present;  but  any  position  was  painful  in 
which  the  weight  of  the  body  pressed  upon  the  part  affected. 


THE  DATA  OBTAINED  BY  OBSERVATION.  99 

Connective-tissue  Dystrophies.  Enlargements  of  the  surface  are 
seen  in  the  so-called  dystrophies.  The  dystrophy  is  usually  due  to  a 
localized  anomalous  overgrowth  of  connective  tissue,  probably  of  tro- 
phic origin.  It  can  easily  be  distinguished  from  oederna  by  the  absence 
of  the  signs  of  oedema,  or  from  local  inflammatory  swelling  by  the 
absence  of  pain,  heat,  and  redness.  The  swelling  occurs  on  the  arms 
and  legs,  usually  on  the  outer  aspects,  and  may  occur  in  various  por- 
tions of  the  trunk.  In  one  of  the  writer's  cases  the  swellings  were 
periodical ;  or,  rather,  the  persistent  swellings  increased  in  size  at  irreg- 
ular intervals. 

Dercum  and  Henry  have  described  cases  of  dystrophy  in  which  the 
enlargements  had  been  attributed  by  others  to  accumulations  of  fat.  The 
patients  presented  marked  subjective  nervous  phenomena,  paresthesias 
of  all  kinds,  with  flushings  and  sensations  of  sinking  and  depression. 
There  were  areas  of  anaesthesia,  pain  and  tenderness  in  the  nerve- 
trunks.     Pain  preceded  the  advent  of  the  swellings. 

Herpes  zoster  occurred  in  Dercum' s  case,  and  other  symptoms  of 
neuritis  were  marked.  The  irregularity  in  the  distribution  of  the  swell- 
ings, their  character  and  mode  of  development,  the  recurrence  of  neu- 
ritis, and  the  absence  of  perspiration  distinguished  dystrophy  from 
lipomatosis  or  excess  of  fat.  The  patients  were  of  a  neurotic  type, 
and  mental  impairment  usually  resulted  in  the  course  of  the  disease. 
The  general  nutrition  failed,  particularly  as  gastro-intestinal  disorders 
ensued. 

Scleroderma.  Scleroderma  is  a  hyperplasia  of  the  subcutaneous 
connective  tissue  in  which  there  is  swelling  with  induration.  It  is 
brawny.  The  term  "  hide-bound"  is  applied  to  this  condition  of  the 
connective  tissue  and  skin,  on  account  of  which  the  tissues  are  almost 
immovable.     There  are  marked  stiffness  and  also  pain. 

In  localized  scleroderma  or  morphcea  the  skin  has  a  waxy  or  dead- 
white  appearance,  is  brawny  and  inelastic.  There  may  be  preliminary 
hyperemia  of  the  skin.  Subsequently  pigmentation  of  the  hyperoemic 
area  takes  place,  causing  changes  in  color,  or  the  pigment  may  atrophy, 
causing  leucoderma.  The  secretion  of  sweat  is  diminished  or  entirely 
abolished.  In  the  diffused  form  the  affection  begins  in  the  extremi- 
ties or  face,  and  is  accompanied  by  a  sense  of  stiffness  or  tension;  the 
skin  is  usually  hard  and  firm,  and  gradually  a  diffuse,  brawny  indura- 
tion develops.  The  skin  cannot  be  picked  up  in  folds.  It  may  appear 
normal,  but  is  generally  very  smooth,  glossy,  and  dryer  than  usual, 
rarely  pigmented.  Scleroderma  may  be  confined  to  a  limb,  or  may 
become  universal.  The  appearance  of  the  face  is  characteristic.  It  is 
expressionless,  and  the  lips  cannot  be  moved,  while  mastication  is  im- 
possible; the  eyes  and  the  nose  are  deformed;  the  hands  become  fixed 
and  the  fingers  immobile  and  contracted  on  account  of  induration  about 
the  joints,  the  deformity  being  called  sclerodactylie.  It  is  thought  to 
be  due  to  a  tropho-neurosis,  or  to  fibrosis  of  the  arteries  of  the  skin, 
with  connective-tissue  overgrowth  in  the  adjacent  areas. 

Brawny  Induration.  (Edema  must  not  be  confounded  with  the 
brawny  induration  of  the  calves  of  the  legs  in  scurvy,  probably  from 


100  GENERAL  DIAGNOSIS. 

deep-seated  hemorrhage.  It  must  be  remembered,  however,  that 
oedema  of  the  ankles  is  very  common  in  this  affection.  Brawny  indu- 
ration may  also  be  found  in  syphilis.  In  a  patient,  recently  in  the 
Presbyterian  Hospital  under  the  writer's  care,  a  brawny  induration 
of  the  thigh,  with  painless  swelling  and  stiffness  of  the  leg,  appeared 
to  be  due  to  syphilis.  It  disappeared  rapidly  under  treatment  with 
potassium  iodide.     The  patient  was  syphilitic. 

Subcutaneous  Nodules  Distinctly  Localized.  Sarcomata. 
The  subcutaneous  nodules  seen  in  these  affections  are  rarely,  if  ever,  . 
confounded  with  oedema  or  other  swellings.  In  sarcoma  the  subcuta- 
neous tumor  becomes  attached  to  the  skin,  and  may  change  its  color. 
It  is  usually  secondary  to  sarcoma  in  some  other  organ  of  the  body. 
When  primary,  or  secondary  to  organs  in  which  there  is  normal  pig- 
mentation, as  the  eye,  they  become  blue  or  bluish-black.  On  palpation 
the  surface  is  found  to  be  rough  and  uneven,  if  the  tumors  are  num- 
erous. 

Primary  melanotic  sarcomata  of  the  skin  can  always  be  distinguished 
by  their  color.  In  both  forms  of  sarcomata  the  general  symptoms  of 
this  affection  daily  become  more  and  more  pronounced,  and  subcuta- 
neous hemorrhages  are  commonly  associated  with  the  local  phenomena. 

The  first  external  evidence  of  lymphosarcoma  may  be  subcutaneous 
nodules  in  an  unusual  situation.  Thus,  in  a  case  under  my  observation, 
a  lymphoid  nodule  was  first  observed  in  the  third  interspace  on  the  right 
side.      Subsequently  the  glandular  involvement  followed. 

Carcixomata.  Subcutaneous  lymphatic  glands  may  be  the  seat  of 
secondary  carcinoma,  and  from  their  location  may  indicate  the  primary 
source  of  the  disease.  The  glands  above  the  left  clavicle  are  sometimes 
secondarily  affected  in  cancer  of  the  stomach.  In  similar  diseases  of 
abdominal  organs  glands  in  the  abdominal  wall  are  enlarged.  The 
subcutaneous  nodules  should  be  removed  and  examined  microscopically. 
The  structures  of  the  umbilicus  (skin  and  subcutaneous  tissues)  enlarge, 
become  nodulated,  and  sometimes  the  seat  of  fungoid  ulceration  in 
abdominal  carcinoma,  particularly  of  the  stomach.  It  must  not  be 
forgotten  that  primary  sarcoma  or  carcinoma  of  the  skin,  limited  to  one 
area,  and  simulating  an  intra-abdominal  growth,  may  occur,  as  in  a  case 
under  my  care  in  the  Philadelphia  Hospital,  operated  on  by  Horwitz. 

Cysticercus  Cellulose.  The  nature  of  the  subcutaneous  nod- 
ules of  cysticercus  are  recognized  by  microscopic  examination.  They 
are  usually  associated  with  the  larvae  in  other  tissues,  hence  the  patient 
complains  of  great  soreness  and  stiffness,  and  may  become  helpless. 
In  a  case  reported  by  Osier  there  were  so  much  numbness  and  tingling 
in  the  extremities,  with  general  weakness,  that  the  patient  was  thought 
to  have  peripheral  neuritis. 

Rheumatic  Xodules.  Subcutaneous  nodules  are  seen  in  rheumatic 
patients  in  the  course  of  the  disease,  or  after  the  attacks.  They  are 
common  in  the  young.  They  are  particularly  frequent  in  cases  of 
rheumatic  endocarditis.  They  may  occur  independently  of  the  artic- 
ular symptoms.  They  may  occur  in  large  numbers,  and  vary  in  size 
from  a  small  shot  to  a  large  pea.     They  are  of  fibrous  structure.     They 


THE  DATA  OBTAINED  BY  OBSERVATION.  101 

are  attached  to  the  tendons  and  fasciae,  particularly  on  the  fingers, 
hands,  and  wrists,  but  may  be  found  on  the  elbows,  knees,  the  scapula4, 
and  the  spines  of  the  vertebrae. 

Syphilitic  Nodes.  Gummata  are  observed  in  the  tertiary  periods 
of  syphilis.  They  must  not  be  confounded  with  the  enlarged  glands. 
They  are  attached  to  the  skin  and  may  from  time  to  time  ulcerate. 
They  may  be  seen  on  the  back  or  buttocks  ;  less  frequently  on  other 
parts. 

The  Temperature.  Fever.  In  conditions  of  health  the  body- 
temperature  is  maintained  constantly  at  about  98.6°  F.  (37°  C). 
This  stability  of  temperature  is  due  to  the  central  regulating  apparatus 
called  the  thermotaxic  mechanism,  which  controls  the  production  and 
the  dissipation  of  heat.  Fever  is  a  condition  characterized  by  an 
increase  of  temperature  with,  usually,  increased  disintegration  of  nitro- 
genous tissue.  The  muscles  and  large  glands,  as  is  well  known,  are 
the  chief  seat  of  heat-production.  Both  heat  production  and  heat- 
dissipation  are  believed  to  be  under  the  control  of  the  nervous  system, 
either  through  the  motor  nerves  or  special  nerves  which  pass  with  them 
to  and  from  definite  centres  in  the  brain,  called  heat-centres.  In  con- 
ditions of  disease  this  thermotaxic  mechanism  may  be  altered  so  that 
the  normal  temperature  is  increased  or  lessened.  (1)  There  may  be 
elevation  of  temperature  from  diminished  dissipation  of  heat,  though 
not  necessarily  increased  nitrogenous  disintegration  and  disordered 
function.  Or  (2)  there  may  be  increased  production  of  heat  with 
diminished  dissipation,  hence  the  temperature  will  naturally  be  higher 
than  if  increased  heat- production  were  accompanied  by  normal  heat- 
dissipation.  (3)  There  may  be  increased  heat-production  and  at  the 
same  time  increased  heat-dissipation,  in  which  case  there  would  be  the 
increased  waste  of  fever  with  or  without  any  elevation  of  temperature. 
(4)  It  is  possible  that  heat-dissipation  may  be  greater  than  heat-produc- 
tion, or  that  the  thermotaxic  mechanism  may  be  disturbed  so  as  to 
promote  loss,  in  which  case  there  will  be  subnormal  temperature. 

Mode  of  Determination  of  Fever.  The  temperature  of  the 
body  can  be  roughly  estimated  by  the  hand  of  the  physician,  but  this 
method  is  open  to  many  sources  of  error.  The  skin  is  at  times  hot 
and  gives  a  deceptive  sensation  of  considerable  elevation  of  tempera- 
ture, whereas  when  tested  by  the  thermometer  the  temperature  is 
found  to  be  but  slightly  or  not  at  all  above  normal.  So,  too,  when 
the  skin  feels  cold  and  clammy  in  phthisis  and  during  a  chill  from  any 
cause,  the  actual  temperature  of  the  body  is  decidedly  above  normal, 
and  may  be  as  high  as  103°  or  104°.  To  insure  accuracy,  therefore, 
it  is  now  almost  the  universal  custom  to  employ  clinical  thermometers. 
They  are  of  a  convenient  size  and  shape  for  insertion  under  the  arm 
or  into  the  mouth,  rectum,  or  vagina.  The  better  ones  arc  provided 
with  an  indestructible  index,  so  that  the  mercury  in  the  capillary  tube 
remains  stationary  at  the  highest  level  to  which  it  rose  when  the  ther- 
mometer was  iu  the  mouth  or  axilla.  When  not  provided  with  such 
an  index  the  reading  must  be  made  when  the  thermometer  is  still  in 
position. 


102  GENERAL  DIAGNOSIS. 

Thermometers  vary  in  the  accuracy  with  which  they  register  tem- 
perature. The  best  ones  are  compared  with  an  acknowledged  standard 
and  sold  with  a  slip  of  paper  which  gives  their  fractional  variations 
from  the  standard.  When  the  exact  temperature  is  a  matter  of  great 
importance,  it  should  be  taken  in  the  rectum  or  vagina,  as  their  tem- 
perature is  more  nearly  that  of  the  body.  It  is  of  advantage  to  take 
the  temperature  in  the  rectum  of  children  or  in  patients  who  are  com- 
atose. This  situation  is  also  a  good  one  to  select  when  a  bath  is  being 
administered.  If  possible,  scybalous  masses  should  be  removed  from 
the  rectum.  At  least  an  incorrect  reading  may  be  obtained  if  the  ther- 
mometer should  happen  to  be  plunged  into  the  faeces  ;  this  must  be 
guarded  against.  From  motives  of  delicacy,  however,  the  axilla  is  to 
be  preferred  to  the  rectum  and  vagina  on  all  ordinary  occasions.  The 
temperature  it  records  is  somewhat  less  than  a  degree  below  that  of 
the  rectum.  The  temperature  of  the  mouth  is  above  that  of  the  axilla 
and  below  that  of  the  rectum.  It  has  some  advantages  over  that  of 
the  ax'lla,  being  more  accessible  and  recording  the  temperature  more 
quickly  and  more  accurately.  Nevertheless,  as  the  physician's  ther- 
mometer is  carried  from  patient  to  patient,  some  place  should  be  selected 
which  is  less  capable  of  absorbing  disease-germs  than  the  mouth.  The 
axilla  is,  therefore,  by  common  consent  the  usual  place  for  taking  the 
temperature.  Observe  two  precautions:  (1)  Before  introducing  the 
thermometer  see  that  there  is  no  undue  moisture  ;  if  there  is,  the  axilla 
should  be  wiped  dry,  otherwise  a  lower  than  a  true  reading  will  be 
obtained.  (2)  See  that  the  instrument  is  inserted  into  the  armpit  and 
does  not  project  beyond  the  posterior  fold,  and  that  it  is  not  caught  in 
a  fold  of  the  undershirt  or  night-dress.  After  the  thermometer  is  in 
pos'tion  the  arm  should  be  brought  gently  across  the  chest  and  kept 
in  that  position  until  the  instrument  is  withdrawn.  The  arm  should 
not  be  held  rigidly,  as  such  muscular  action  increases  the  hollow  of  the 
armpit  and  may  keep  the  sides  apart,  instead  of  in  contact,  as  they 
should  be  to  make  a  correct  reading.  The  length  of  time  required  to 
take  the  axillary  temperature  will  depend  upon  the  instrument  used  ; 
generally  from  five  to  eight  minutes  are  required.  Some  very  delicate 
thermometers  register  in  one  minute,  but  they  are  too  fragile  for  ordi- 
nary use.  If  the  index  is  in  such  a  position  that  it  can  be  seen,  it  is 
proper  to  withdraw  the  thermometer  when  the  mercury  has  ceased  to 
rise  for  two  minutes. 

The  index,  of  course,  must  be  shaken  down  to  normal,  or  slightly 
below  normal,  before  the  thermometer  is  again  ready  for  use;  and  the 
instrument  must  be  carefuly  cleansed  after  use. 

In  children  who  are  restless,  the  temperature  may  be  taken  in  the 
groin,  as  the  folds  of  fat  readily  admit  of  completely  enveloping  the 
bulb  of  the  thermometer.  The  height  to  which  the  mercury  rises  will 
correspond  to  the  temperature  of  the -axilla.  The  temperature  of  the 
urine  corresponds  exactly  with  that  of  the  body,  if  taken  when  freshly 
passed  and  during  the  act,  a  method  only  applicable  in  the  case  of  males. 
Sometimes  this  method  of  securing  the  temperature  is  resorted  to,  par- 
ticularly in  patients  who  may  act  as  malingerers,  when  it  is  desirable  to 
have  the  temperature  taken  in  the  physician's  presence. 


THE  DATA  OBTAINED  BY  OBSERVATION.  103 

If  the  mouth  is  selected  as  the  place  in  which  the  temperature  is  to 
be  taken,  care  should  be  exercised  that  the  thermometer  is  placed  under- 
neath the  tongue,  or  along  its  side  between  it  and  the  lower  jaw,  and 
retained  in  position  by  the  lips  of  the  patient.  If  the  teeth  are  set 
firmly  on  the  thermometer,  it  maybe  broken,  or,  what,  is  of  still  greater 
importance,  it  will  be  tilted  out  of  position  and  a  correct  reading  will 
nut  be  obtained.  The  lips  should  be  closed  and  breathing  be  carried 
on  through  the  nostrils.  Four  to  seven  minutes  is  sufficient  time  to 
allow  it  to  remain  in  position.  The  patient  should  not  have  taken  ice 
or  anything  cold  prior  to  the  observation. 

Observations  of  the  temperature  should  be  made  at  least  twice  a 
day,  in  the  morning  and  evening,  and,  as  far  as  possible,  at  the  same 
hour  on  successive  days.  It  is  frequently  desirable  to  have  the 
temperature  taken  every  two  or  three  hours,  and  sometimes  at  more 
frequent  intervals.  This  is  particularly  the  case  if  observations  of 
the  indications  for,  and  the  effect  of,  antipyretic  treatment  are  to  be 
made. 

In  obscure  cases  the  observations  should  be  repeated  at  night  as  well 
as  during  the  day.  In  this  manner  the  presence  of  unsuspected  tuber- 
culosis may  be  revealed,  or  the  occurrence  of  suppuration  in  some  por- 
tion of  the  body  definitely  determined.  It  should  not  be  forgotten, 
however,  that  the  temperature  may  be  taken  too  frequently  for  the 
patient's  good,  the  disturbance  of  his  needed  rest  being  distinctly 
harmful. 

As  the  general  range  of  temperature  and  its  diurnal  variations  are 
of  more  importance  than  the  absolute  temperature  at  any  one  time, 
thermometers  not  perfectly  accurate  in  their  reading  are  still  good 
enough  for  clinical  and  therapeutic  purposes. 

Physiological  Variations  of  Temperature.  The  tempera- 
ture is  subject  to  'physiological  variations.  1.  It  rises  from  seven  or 
eight  in  the  morning  until  seven  or  eight  in  the  evening,  at  which  time 
it  reaches  its  maximum.  It  then  begins  slowly  to  fall,  reaching  its 
lowest  point  in  the  early  hours  of  the  morning,  between  two  and  four. 
This  diurnal  fluctuation  does  not  usually  amount  to  more  than  a  degree. 
2.  Exercise,  etc.  Violent  exertion  raises  the  temperature,  and  so  does 
a  heated  atmosphere,  cold  having  a  contrary  effect.  3.  Age.  In 
infants  and  young  children,  up  to  puberty,  the  temperature  has  a  some- 
what higher  range,  and  is  subject  to  greater  variations  than  at  a  later 
period.  In  very  old  persons  the  temperature  may  be  subnormal.  The 
normal  axillary  temperature  of  adults  is  98.6"°  F.  The  period  in  the 
twenty-four  hours  in  which  the  temperature  is  at  its  lowest  ebb  is  from 
]'2  p.m.  to  4  a.m.  It  may  then  be  subnormal.  The  writer  has  known 
an  over-cautious  parent  to  make  this  physiological  fall  the  subject  of 
meddlesome  observation  and  ill-judged  treatment. 

Pathological  Variations  of  Temperature.  An  elevation  of 
temperature  above  the  normal,  not  to  be  accounted  for  by  external 
heat  or  severe  exhaustion,  may  be  considered  febrile,  and  is  patholog- 
ical. The  range  of  febrile  temperature  varies  from  above  normal  to 
105°  or  100°  in  ordinary  cases.  A  range  above  106°  may  occur,  but  is 
not  usually  compatible  with  life.      Certain  terms  have   been  applied  to 


104 


GENERAL  DIAGNOSIS. 


various  degrees  of  temperature,  to  iudicate  in  a  general  way  the  degree 
of  fever  : 

Very  low,  or  collapse  temperature. 

Subnormal  temperature. 

Normal  temperature. 

Slightly  above  normal  or  sub-febrile  temperatures. 

Moderately  febrile  temperature. 

Highly  febrile  temperature. 

Hyperpyretic  temperature 

(From  Fixlaysox.  ) 

The  Degree  of  Danger.  In  general  the  degree  of  clanger  to 
the  patient  increases  with  the  height  of  the  fever,  but  the  duration  of 
the  high  fever  modifies  this  greatly.  A  temperature  of  106°  on  the 
second  or  third  day  of  an  acute  lobar  pneumonia  is  not  rare,  such  cases 
frequently  ending  in  recovery,  while  a  temperature  of  105°  in  the 
second  or  third  week  of  typhoid  fever  is  of  much  graver  significance. 
Da  Costa  has  reported  a  case  of  cerebral  rheumatism  in  which  the 
axillary  temperature  reached  110°,  yet  the  patient  recovered.  In  the 
case  of  injury  of  the  spine,  reported  by  Teale,  the  extraordinary  tem- 
perature of  122°  was  recorded,  and  the  temperature-range  for  clays 
was  between  112°  and  114°.     The  patient  recovered. 


Below 

/35° 
136 

Cent 

.=  950°  Fahr 
=  96.8 

About 
normal 

f  36J 
137" 

« 

=  97.7       " 
=  98.6 

About 

(37* 
\  38" 

Us* 

!< 

=  99.5      " 
=100  4 
=101.3 

About 

f  39 

\39* 

U 

=102.2      " 
=103.1 

About 

J  40 

140} 

If 

=104.0      " 
=104.9 

Above 

41 

a 

=105.8      " 

107° 
106 c 
105 = 
104' 
103° 
102° 
101° 
100° 


«H 

rH-HsjjJ  !  ; 

s   '     ,  ' 

4JJJ1* 

s  2   -    :    -   =  |D 

b 

T- 1  -  j  -  j  ~  I  -  '  o-E— --L- — L_:_-.  2. 
Ml                   .      .      1      ! 

i  ; ! ! — 

1  !    \  1  i 

1"  .,                      0 

^m 

— i — . — \ 1 

4 

1  I  !  i  : 1 

Malarial  intermittent  fever.    Quotidian  type. 

The  Types  of  Fever.  Fevers  are  divided,  in  accordance  with 
the  character  of  their  range,  into  certain  definite  types.  The  types  may 
be  indicative  of  special  processes.  It  is  certain  that  the  recognition  of 
a  peculiar  type  forms  a  positive  aid  to  diagnosis.  The  fever  that  con- 
tinues for  more  than  two  days,  in  which  the  difference  between  the 


THE  DATA  OBTAINED  BY  OBSERVATION. 


105 


daily  maximum  and  minimum  of  temperature  is  less  than  2°,  is  known 
as  continued  fever.  (See  Fig.  9.)  The  fever  existing  more  than  two 
days,  in  which  the  daily  difference  is  greater  than  2°,  is  known  as  remit- 
tent fever.     Further,  a  fever  in  which  there  is  a  rise  of  temperature 


Fig-  4. 


Malarial  intermittent  fever.    Tertian  type. 


Fig.  5. 


Malarial  intermittent  fever.    Quartan  type. 

followed  by  a  fall  to  or  below  the  normal,  occurring  periodically,  is 
known  as  intermittent  fever.  The  paroxysms  may  occur  daily,  every 
second  or  third  day,  or  once  a  week.  When  the  paroxysms  occur  daily, 
the  intermittent  is  of  quotidian  type  (see  Figs.  3  and  6);  every  second 
day,  tertian  type,  one  day  intervening  without  fever  (sec  Fig.  4);  every 
third  day,  quartan  type,  two  apyrctic  days  intervening.      (  Fig.  5. ) 


106  GENERAL  DIAGNOSIS. 

The  Course  of  the  Fever.  Fevers  frequently  have  a  definite 
course,  known  as  (1)  the  initial  stage;  (2)  the  fastigiunij  (3)  the  period 
of  defervescence.  During  the  initial  stage  the  temperature  rises  higher 
each  hour,  or  if  extended  over  days,  each  day,  than  the  preceding  hour 
or  clay — in  this  latter  instance  interrupted  by  the  daily  fluctuations. 
The  stage  may  last  from  a  few  hours,  as  in  a  paroxysm  of  intermittent 
fever,  to  four  or  five  days,  as  in  typhoid  fever.  In  this  stage  we  have 
a  chill  such  as  characterizes  the  onset  of  an  intermittent  fever,  or  the 
recurrent  chills  or  chilliness  with  headache  and  backache  that  attend 
the  first  four  or  five  days  of  typhoid  fever.  During  this  stage,  also, 
the  heat-dissipation  from  the  cutaneous  surface  is  diminished,  and  the 
total  heat-dissipation  is  less.  When  the  hand  is  placed  upon  the  patient 
the  surface  will  be  found  to  be  cool,  whereas  the  temperature  in  the 
mouth  or  rectum  will  be  found  to  be  far  above  the  normal.  The 
patient  complains  of  the  coldness  or  chilliness,  and  the  low  temperature 
of  the  surface  is  indicated  by  the  shrunken  hand,  the  pallid,  pinched 
face.  The  peripheral  arteries  are  contracted,  and  hence  cause  diminu- 
tion in  the  amount  of  blood  to  warm  the  skin. and  to  compensate  for 
the  loss  by  radiation  and  conduction.  This  peripheral  contraction  is 
the  cause  of  the  chilliness  and  the  fall  in  the  temperature  of  the  skin. 

During  the  second  period  of  the  course  of  pyrexia — the  fastigium — 
the  temperature  of  the  body  attains  the  highest  point,  and  remains 
almost  stationary,  or  may  vary  but  a  degree  or  two  between  maximum 
and  minimum.  It  may  last  a  few  hours  or  from  two  days  to  three  or 
more  weeks,  during  which  time  it  may  oscillate  to  the  maximum  point 
of  the  first  day.  The  temperature  of  the  surface  of  the  body- is  about 
the  same  as  that  of  the  deep  parts,  particularly  in  cases  of  pneumonia, 
measles,  and  scarlet  fever.  In  typhoid  fever,  acute  rheumatism,  and 
phthisis,  during  this  period,  there  may  be  a  difference  in  the  external 
temperature  and  the  temperature  taken  in  the  cavities,  as  the  mouth 
or  rectum.  More  or  less  antagonism  between  heat-production  and 
heat-loss  exists  under  these  circumstances.  The  latter  may  be  greater 
than  the  former,  if  the  skin  perspires  freely,  as  in  rheumatism.  The 
temperature  then  remaining  high  indicates  that  the  production  of  heat 
must  be  proportionately  increased,  and  hence  far  greater  than  in  the 
cases  in  which  the  external  and  internal  temperature  are  nearly  the 
same.  (See  Fig.  7  :  the  fastigium  here  occurs  in  the  first  three  days. 
In  Fig.  9  the  fastigium  lasts  until  the  crisis.) 

In  the  period  of  defervescence  the  temperature  falls  to  the  normal. 
In  this  period  an  attempt  is  made  by  the  economy  to  return  to  a  phys- 
iological state,  in  which  heat-production  and  heat-loss  are  evenly  bal- 
anced. The  state  of  pathological  pyrexia  has  come  to  an  end.  The 
termination  may  be  by  crisis.  (See  Figs.  4  and  10.)  "When  this  takes 
place  the  perturbation  of  the  thermotaxic  mechanism  must  be  very 
great,  but  the  normal  state  is  at  once  resumed.  In  other  cases  the 
termination  is  by  lysis — the  temperature  falls  a  degree  or  two  each  day 
until  the  normal  is  reached.  (See  chart  of  Typhoid  Fever.)  It  seems 
that  the  thermotaxic  mechanism  of  health  is  restored  with  difficulty. 
In  some  cases,  in  the  period  of  defervescence  the  aberrations  are  very 
remarkable.      It  seems  as  if  the  thermotaxic  mechanism  which  controls 


THE  DATA  OBTAINED  BY  OBSERVATION.  107 

heat-loss  were  in  a  convulsive  state.  The  temperature  rises  and  foils 
irregularly,  gradually  resuming  the  normal  only  as  the  strength  of  the 
patient  increases. 

The  Mode  of  Onset  of  the  Initial  Stage.  The  onset  may 
be  sudden  or  gradual.  1.  The  sudden  onset  occurs  in  acute  diseases, 
as  tonsillitis,  pneumonia,  and  gastro-intestinal  disorders  of  children, 
in  erysipelas,  and  in  intermittent  fever.  Within  a  few  hours  the  max- 
imum of  temperature  is  reached.  (See  Fig.  10.)  2.  The  mode  of 
onset  may  be  gradual.  The  initial  stage  is  prolonged  under  these 
circumstances,  as  in  cases  of  typhoid  fever.  (See  chart  of  Typhoid 
Fever.) 

The  Mode  of  Decline  in  the  Period  of  Defervescence. 
A  sudden  fall  of  temperature  at  the  termination  of  a  disease  is  known 
as  crisis,  which  is  also  attended  by  copious  perspiration,  a  "  critical 
sweat/'  or  by  the  passage  of  a  large  quantity  of  urine,  and  sometimes 
by  several  large  liquid  stools.  The  pulse-rate  and  respirations  fall  cor- 
respondingly with  the  temperature.     (See  Fig.  10.) 

The  defervescence  may,  however,  occupy  several  days,  in  which 
case  it  is  called  lysis.  In  this  case  the  sweating  is  less  marked,  but 
may  recur  for  several  days.  The  slowing  of  the  pulse  and  respiration 
likewise  takes  place  gradually.     (See  chart  of  Typhoid  Fever.) 

Diseases  of  sudden  onset  usually  terminate  with  sudden  decline,  and 
conversely  in  diseases  Avith  a  prolonged  onset  the  decline  is  also  pro- 
longed. Many  cases  which  naturally  terminate  by  crisis  may  end  by 
lysis.  This  irregular  termination  is  usually  due  to  a  complication. 
(See  Fig.  7.)  For  instance,  in  measles,  pneumonia  is  usually  the  causal 
complication,  while  in  pneumonia  it  is  empyema  or  endocarditis. 

The  Daily  Eange  of  the  Prolonged  Initial  Stage,  and 
the  Fastigium.  The  daily  range  of  the  temperature  in  fever  gener- 
ally corresponds  to  the  normal  variations.  That  is,  the  temperature  is 
higher  in  the  evening  than  in  the  morning.  The  difference  in  the 
daily  range  varies  in  the  different  types  of  fever — generally,  as  pre- 
viously noted,  the  continued  fevers  show  a  smaller,  the  intermitting 
fevers  a  larger,  difference  between  morning  and  evening  temperature. 

Sometimes  there  is  inversion  of  the  normal  range.  The  evening 
temperature  is  lower  than  the  morning;  although  a  rare  condition,  this 
is  of  serious  import.  It  is  seen  in  the  more  severe  cases  of  typhoid 
fever,  and  occasionally  in  tuberculosis. 

Recrudescence.  In  many  cases  the  fever  returns  after  the  tem- 
perature has  fallen  to  the  normal.  This  may  occur  from  a  number  of 
causes.  It  may  be  from  perturbation  of  the  nervous  system  on  accounl 
of  excitement,  overexertion,  loss  of  sleep;  or  from  indigestion.  Slight 
aberrations,  which  in  health  would  not  modify  the  temperature,  cause 
pronounced  oscillations  in  illness.  Recrudescence,  further,  may  be 
produced  by  a  relapse.  After  the  afebrile  period  following  typhoid 
fever,  for  instance,  the  temperature  may  rise  and  a  full  recurrence  <>(' 
the  disease  take  place. 

The  Symptoms  of  Fever.  Pyrexia,  or  increased  temperature,  is 
not  the  only  evidence  of  fever.  The  production  of  heal  within  the 
body  is  not  due  to  increased  tissue-change  alone.      Et  may  be  due,  for 


108  GENERAL  DIAGNOSIS. 

instance,  to  increased  oxidation  of  sugar,  which  is  part  of  the  substance 
of  the  body.  Physiologists  have  found  that  a  high  temperature  may 
take  place,  and  yet  the  quantity  of  urea  and  of  carbonic  acid  discharged 
may  not  be  as  great  as  that  discharged  by  a  healthy  person  who  is 
taking  active  exercise,  or  who  has  eaten  a  large  meal.  It  must  be 
remembered,  therefore,  that  it  is  not  heat-production  aloue,  but  alter- 
ations of  heat-regulation,  which  cause  pyrexia  and  its  phenomena. 

Wasting.  Wasting  of  the  body  is  a  striking  symptom  of  fever. 
There  is  no  doubt  that  even  in  fever  of  moderate  duration  ffreat  wast- 
mg  of  the  solid  structures  takes  place.  At  the  same  time  the  blood 
wastes  (see  observations  of  Thayer),  and  the  various  fluids  of  the  body 
are  also  diminished;  hence  the  disorders  due  to  diminished  secretion  of 
glands  are  prominent  in  the  course  of  fever.  Diminution  of  secretion 
in  the  gastro-intestinal  tract,  causing  thirst,  loss  of  appetite,  indigestion, 
and  constipation,  indicates  the  wasting  of  the  fluids.  Scanty  urine  of 
high  color  and  specific  gravity  is  due  to  the  same  cause. 

The  Pulse-rate.  Acceleration  of  the  pulse  is  one  of  the  phe- 
nomena that  attend  pyrexia.  While  increased  pulse-frequency  is  the 
rule,  and  is,  in  all  probability,  a  result  of  the  increase  in  temperature, 
other  circumstances  may  cause  a  change  in  the  pnlse-rate  in  pyrexia. 
Thus,  in  basilar  meningitis,  although  there  may  be  a  high  fever,  the 
pulse  is  not  more  frequent.  On  the  other  hand,  some  diseases,  usually 
accompanied  by  fever,  as  diphtheria  and  peritonitis,  may  be  afebrile, 
and  yet  the  pulse  be  very  much  accelerated. 

Arterial  Tension.  The  rapidity  with  which  the  blood  flows  in 
fever  and  the  arterial  tension  do  not  bear  a  due  proportion  to  the  ac- 
celeration of  the  pulse.  The  true  febrile  pulse  is  not  dicrotic.  In  the 
early  stages  of  fever  the  pulse  is  large  and  hard,  the  arterial  tension  is 
high,  and  the  vessels  full.  In  the  later  stages  arterial  relaxation  takes 
place,  and  the  pulse  becomes  soft  and  feeble,  and  often  small,  with  low 
pressure.  The  pulse  is  rapid,  and  clicrotism,  or  even  hyper-dicrotism, 
now  becomes  a  prominent  feature.  The  heart  beating  rapidly  empties 
itself  incompletely  and  discharges  less  rather  than  more  blood  into  the 
arteries.  The  impairment  of  the  cardiac  beats  is  no  doubt  due  to  the 
degenerations  which  take  place  on  account  of  the  high  temperature, 
and  is  not  dependent  upon  any  special  febrile  affection.  Such  changes 
also  take  place  in  the  glands,  particularly  the  liver  and  kidneys,  and 
are  known  as  parenchymatous  degenerations  or  cloudy  swelling.  These 
changes  in  the  cardiac  muscle  may  induce,  in  the  later  stages  of  fever, 
thrombi,  and  cause  death  from  heart-clot. 

The  Respiration.  The  respirations  are  increased  in  fever,  prob- 
ably because  of  the  close  dependence  of  the  regulating  centre  of  res- 
piration on  that  of  the  heart.  The  heated  blood  acts  as  a  stimulant 
to  the  respiratory  centre.  As  proof  of  this  the  hurried  respiration  of 
pneumonia  ceases  as  soon  as  the  temperature  falls,  notwithstanding  the 
fact  that  the  affected  part  of  the  lung  remains  hepatized. 

Cerebral  Symptoms.  Delirium  and  other  nervous  symptoms  may 
attend  fever.  They  are  not  dependent  upon  the  increased  temperature 
of  the  blood  alone.  No  relation  appears  to  exist  between  the  intensity 
of  the  fever  and  the  severity  of  the  delirium.      In  relapsing  fever  a 


THE  DATA  OBTAINED  BY  OBSERVATION.  109 

temperature  of  106°  occurs  with  the  mind  clear.  In  certain  cases  of 
typhoid  fever  a  temperature  of  103°  is  attended  with  marked  delirium. 
If  fever  persists  for  a  short  time,  a  low  asthenic  state,  so-called  ady- 
namia, may  develop.  Because  the  symptoms  resemble  those  of  typhus 
fever,  the  term  typhoid  is  also  applied  to  them,  and  the  condition  about 
to  be  described  is  known  as  the  typhoid  state.  The  expression  is 
dull  and  heavy,  the  capillaries  of  the  face  are  congested.  There  are 
stupor  and  sluggishness  of  mental  processes,  so  that  the  patient  is  slow 
in  answering  questions.  The  stupor  is  attended  with  low  muttering 
delirium,  and  may  be  followed  by  complete  unconsciousness.  The 
pupils  are  contracted,  the  eye  heavy  and  dull.  The  patient  is  so  pros- 
trated that  he  slips  down  into  the  bed  from  the  pillow.  There  is  marked 
subsultus  tendinum.  The  tongue,  if  protruded,  comes  out  slowly  and 
is  tremulous.  It  is  dry  aud  brown,  and  the  mouth  and  teeth  are  cov- 
ered with  sordes.  The  sensibilities  are  blunted  so  that  food  and  drink 
are  not  asked  for,  or  particularly  relished  if  given.  Involuntary  dis- 
charges take  place  from  the  rectum  and  bladder,  and  the  incontinence 
of  retention  ot  the  urine  arises.  The  pulse  is  small,  feeble,  and  dicrotic, 
the  heart-sounds  are  weak  and  feeble.  The  first  sound  becomes  short 
and  snappy  like  the  second,  or  may  be  absent  entirely.  Venous  stases 
take  place  in  the  dependent  portions,  particularly  in  the  back  of  the 
lungs.  As  oedema  or  hypostatic  congestion  advances  the  breathing 
becomes  shorter  and  labored.  More  or  less  cyanosis  then  creeps  over 
the  general  surface.  The  urine  becomes  more  and  more  scanty  and 
high-colored,  contains  albumin,  and  sometimes  blood. 

The  typhoid  state  may  continue  for  many  days,  or  even  last  two  or 
three  weeks,  although  not  in  so  advanced  a  degree  as  has  been  described. 
It  is  more  likely  to  supervene  when  there  is  excessively  high  tempera- 
ture, but  it  also  occurs  in  the  course  of  a  prolonged  illness  with  a  tem- 
perature of  moderate  degree — that  is,  103°  F.  Although  it  is  in  all 
probability  due  to  the  direct  effects  of  heat  upon  the  nerve-centres  and 
the  organs  of  the  body,  yet  there  are  cases  in  which  the  temperature 
is  not  high,  and  yet  all  the  symptoms  of  the  typhoid  state  supervene. 
While  the  typhoid  state  is  common  to  typhoid  fever,  it  occurs  also  in 
pneumonia  and  septiccemia,  and  may  even  be  seen  in  its  most  typical 
form  in  other  conditions  in  which  fever  is  not  a  pronounced  symptom; 
thus,  in  uraemia,  in  the  later  stages  of  softening  of  the  brain,  in  paresis, 
or  in  allied  nervous  diseases,  the  symptoms  of  the  typhoid  state  are 
most  striking.  In  this  class  of  cases  it  certainly  cannot  be  attributed 
to  the  fever,  but  is,  in  all  probability,  due  to  the  depressing  effect  on 
the  nervous  system  of  material  which  should  be  excreted  from  the  body, 
a  view  which  has  been  advocated  by  Murchison,  Flint,  and  others. 

Ataxia,  or  the  ataxic  state,in  fever,  is  a  condition  the  opposite  of  the 
adynamic,  or  typhoid  state.  In  the  latter  there  is  weakness,  while  in 
the  former  there  is  exhibition  of  strength.  In  the  latter  the  nerve- 
centres  and  the  vital  processes  are  depressed;  in  the  former  they  are 
stimulated.  Ataxia  as  an  exhibition  of  strength  is  characterized  by  a 
strong  pulse,  by  active  violent  delirium,  so  that  it  is  almost  impossible 
to  keep  the  patient  in  bed;  by  evidence  of  great  muscular  strength. 
The  face  is  flushed,  bright-red  in  color;  the  eyes  injected,  bright,  and 


HO  GENERAL  DIAGNOSIS. 

active.  The  tongue  is  furred,  but  is  not  necessarily  dry  or  brown. 
The  delirium  may  be  constant  or  paroxysmal,  and  is  often  maniacal  in 
character.  The  temperature  of  the  body  is  high,  and  a  sensation  of 
intense  heat  is  imparted  to  the  hand  when  placed  on  the  surface  of  the 
trunk.  The  patient  may  complain  of  a  bursting,  intense  headache. 
If  the  ataxic  state  is  not  controlled  after  a  few  days,  or  at  the  most  a 
week,  the  patient  becomes  exhausted  and  lapses  into  stupor,  which  may 
proceed  to  coma.  In  some  forms,  particularly  in  children,  convulsions 
may  accompany  the  excessively  high  temperature  and  be  followed  by 
coma.  The  so-called  coma  vigil  may  supervene.  The  same  exhibi- 
tion of  strength  is  shown.  Ataxia  is  seen  notably  in  scarlet  fever, 
"  cerebral  "  pneumonia,  and  in  forms  of  typhoid  fever.  The  peculiar 
behavior  of  the  temperature  and  nervous  symptoms  in  this  affection 
and  in  apex  pneumonia,  or  so-called  pneumonia  of  the  cerebral  type, 
have  led  observers  to  mistake  such  cases  for  actual  cerebral  disease. 
Frecniently  they  have  been  admitted  into  insane  asylums  for  supposed 
mania.  The  true  nature  of  such  cases  is  often  mistaken,  and,  because 
of  lack  of  attendants,  the  patients  have  jumped  from  the  window  or 
done  violence  to  themselves  in  other  ways. 

It  is  as  difficult  to  determine  the  exact  cause  of  the  extreme  pertur- 
bation of  the  nervous  system  in  febrile  ataxia  as  in  adynamia.  It  may 
be  due  to  a  high  temperature  acting  on  nerve-centres;  or  to  a  poison, 
as  the  special  toxin  of  the  infection  which  has  caused  the  fever. 

The  presence  of  fever  may  be  suggested  by  flushing  of  the  face. 
This  may  be  general  or  local.  The  local  flush  of  phthisis  and  of  pneu- 
monia has  previously  been  referred  to.  Dryness  and  pungency  of 
the  skin  occur  in  fever.  In  former  times  the  sense  of  heat  was  given 
different  attributes,  said  to  be  distinctive  of  various  affections.  Hence 
the  terms  calor  mordax,  etc.  Thus  the  sensation  to  the  hand  of  the 
heat  in  tvphus  fever  was  said  to  be  peculiar  and  characteristic.  The 
decree  of  fever  was  determined  by  the  sense  of  touch.  The  thermom- 
eter has  displaced  this  method  of  reckoning  temperature.  Sweating  is 
a  condition  habitual  in  some  fevers.  It  may  occur  throughout  the 
course  of  the  disease,  or  at  certain  stages  only  as  instanced  by  the  early 
morning  or  night-sweats  of  tuberculosis.  In  such  cases  it  is  cold  and 
clammy.  The  same  sweatings  are  common  in  the  fever  of  deep- 
seated  suppuration  and  in  disease  of  the  bones.  Sweating  in  deferves- 
cence marks  the  occurrence  of  crisis. 

Headache  axd  Paix  in  the  Back  occur  in  the  acute  specific 
fevers  in  the  initial  stage.  One  or  both  are  nearly  always  present,  but 
in  different  affections  they  have  diagnostic  significance.  Thus  severe 
pain  in  the  back  is  more  pronounced  in  tonsillitis  and  smallpox,  severe 
headache  in  cerebrospinal  meningitis,  and  protracted  throbbing  head- 
ache in  typhoid  fever. 

Subnormal  Temperature.  A  temperature  below  the  normal  may 
occur  independently  of  fever,  but  it  may  follow  diseases  with  more  or 
less  prolonged  pyrexia.  It  occurs  in  the  course  of  wasting  diseases,  as 
in  cancer,  in  starvation,  at  times  in  anaemia.  It  is  seen  habitually  in 
myxoedema,  and  occasionally  in  diabetes.   In  certain  forms  of  tubercu- 


THE  DATA   OBTAINED  BY  OBSERVATION. 


Ill 


losis  it  may  extend  over  a  long  period  of  time,  as  in  tuberculous  peri- 
tonitis. (See  chart  under  Tubercular  Peritonitis.)  In  cases  of  cere- 
bral abscess  the  temperature  is  often  subnormal. 

Sometimes  the  subnormal  temperature  may  occur  suddenly,  to  be 
followed  by  a  return  to  normal  or  even  a  rise  above  normal.  The  sud- 
den fall  may  occur  in  shock,  or  in  hemorrhage  from  any  cause.  It  may 
take  place  from  disturbance  of  the  nerve-centres,  as  from  apoplexy, 
thrombosis,  Or  embolism  of  the  brain,  causing  shock  or  other  disturb- 
ance of  the  thermotaxic  mechanism.     It  is  characteristic  of  cholera. 


Fig.  6. 


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Subnormal  temperature.    Oscillations  in  hepatic  intermittent  fever  with  jaundice.    Catarrh  of 
ducts,  with  diffused  hepatitis.    G.  W.,  aged  60.    Philadelphia  Hospital,  1877. 


In  the  course  of  organic  heart  disease  pulmonary  embolism  is  also 
attended  by  subnormal  temperature.  In  many  of  these  instances  the 
temperature  will  rise  (reaction)  after  the  shock,  if  the  latter  is  not  too 
profound.  This  is  notably  the  case  in  apoplexy  and  in  embolus  or 
thrombus,  because  of  local  irritation  or  a  secondary  softening.  In 
apoplexy  the  rise  in  temperature  will  occur  either  from  central  disturb- 
ance of  the  thermic  mechanism  or  from  secondary  inflammation  about 
the  clot.      A  subnormal  temperature  in  the  course  of  fever  may  be  due 


112  GENERAL  DIAGNOSIS. 

to  au  accident  or  complication,  as  hemorrhage  in  disease  of  the  lungs, 
or  in  typhoid  fever,  or  perforation  of  the  intestine  in  the  latter  condi- 
tion. It  may  attend  the  crisis  of  acute  disease.  More  or  less  collapse 
usually  attends  the  pathological  fall  of  temperature  below  the  normal. 
"While  such  fall  is  the  result  of  accident  in  many  of  the  diseases  men- 
tioned, in  others  it  is  a  part  of  the  process. 

The  chart  (Fig.  6)  represents  the  effect  of  a  local  process  in  the 
largest  gland  of  the  body  upon  the  general  temperature.  It  is  possibly 
a  septic  temperature,  although  the  observation  was  made  before  the 
days  of  bacteriological  research.  The  extreme  low  temperature  is 
remarkable. 

The  Diagnostic  Significance  of  Fever.  Its  Clinical  Causes. 
The  presence  of  fever  is  itself  of  diagnostic  importance.  It  usually 
excludes  hysteria  at  once,  as  well  as  the  feigning  of  disease.  It  indi- 
cates that  one  of  several  morbid  processes  is  present.  The  morbid 
processes  which  give  rise  to  fever  are  :  First,  infectious  disease,  acute 
or  chronic.  Second,  inflammations,  which  may  be  confined  to  the 
mucous  membranes,  or  to  the  surface  of  the  skin,  or  involve  the  various 
viscera,  or  the  membranes  in  relation  with  the  viscera.  The  fever 
under  these  circumstances  may  be  due  to  irritation  of  the  heat-centres 
or  the  thermotaxic  mechanism  by  ptomaines,  or  chemical  principles 
derived  from  the  inflamed  parts.  The  inflammation,  on  the  other  hand, 
may  be  suppurative  or  septic.  The  fever  is  then  higher  than  in  the 
former  condition,  and  is  most  marked  when  pus  is  closely  confined. 
On  account  of  the  local  septic  process,  toxins,  or  chemical  poisons  of 
some  kind,  are  absorbed.  The  purulent  inflammation  may  be  seated 
in  the  connective  tissue,  the  bones,  the  brain,  the  liver  or  kidney,  or 
the  serous  membranes.  "When  the  local  inflammation  sets  up  intense 
infection  of  the  system  by  emboli,  the  formation  of  metastatic  abscesses 
takes  place.  The  fever  that  attends  the  process  assumes  a  peculiar 
intermittent  character,  and  is  known  as  pyamiic.  Third,  in  certain 
intoxications  of  the  system,  as  from  ptomaines  in  gastro-intestinal  dis- 
order, or  affections  of  the  liver,  and  in  poisoning  from  various  causes, 
a  fever  may  be  set  up.  The  same  mechanism  attends  the  process. 
Fourth,  fever  may  be  of  central  origin,  from  disease  of  the  brain 
involving  the  centres  controlling  heat,  or  from  disease  in  proximity  to 
the  heat-centres.  It  may  arise  in  cases  of  brain-tumor,  in  cases  of 
apoplexy,  and  of  thrombosis.  The  centres  may  also  be  irritated  by 
direct  exposure  to  external  heat  alone,  or  possibly  by  poisons  generated 
within  the  system  on  account  of  the  heat,  as  in  sunstroke.  Fifth,  an 
irregular  form  of  fever  is  seen  in  ansemia  and  in  starvation;  while  such 
form  is  of  clinical  significance,  pathologically  it  seems  to  be  of  the  same 
cause  as  others  mentioned.  Sixth,  a  pronounced  peripheral  irritation 
or  sensation  of  pain,  reflexly  altering  the  thermotoxic  mechanism,  will 
produce  fever.  Hence,  in  iritis  or  orchitis  a  fever  arises  out  of  all 
proportion  to  the  local  inflammation.  Finally,  cases  of  continued  fever 
exist  that  have  not  thus  far  been  classified.  One  of  the  nurses  of  the 
Presbyterian  Hopital  with  a  continued  temperature  from  100°  to  103° 
was  under  my  care  for  two  months.      Xo  general  or  local  condition 


THE  DATA  OBTAINED  BY  OBSERVATION.  113 

could  account  for  it.  The  patient  was  emaciated.  She  had  had  two 
vcars  of  very  hard  work.  Although  fever  kept  up,  the  appetite  was 
good.  Careful  and  abundant  feeding,  with  rest  for  many  weeks,  caused 
the  temperature  to  fall  to  normal,  with  complete  recovery.  I  looked 
upon  it  as  a  nervous  fever;  an  expression  of  exhaustion.  Fagge  refers 
to  such  cases. 

The  Significance  of  the  Initial  Stage.  1.  In  the  initial 
stage  of  fever  sudden,  excessive  rise  of  temperature  from  a  condition 
of  apparent  health  argues  against  any  of  the  acute  specific  fevers,  except 
scarlet  fever.  It  is  of  more  frequent  occurrence  in  acute  gastric  or 
gastro-intestinal  catarrh  in  children,  than  in  any  other  condition  in  the 
same  class  of  patients.  It  may  be  due  to  a  pneumonia,  and  is  particu- 
larly significant  in  adults,  if  attended  by  a  pronounced  rigor.  In  chil- 
dren convulsions  may  replace  the  chill.  The  sudden  rise  may  be  due 
to  malaria,  in  which  case  it  is  also  accompanied  by  a  chill  and  followed 
by  free  sweating.  It  may  also  be  due  to  affections  of  the  throat,  to 
follicular  or  phlegmonous  inflammation  of  the  tonsils.  The  throat 
must  always  be  examined  in  cases  of  sudden  high  temperature. 

In  children  if  pain  attends  any  inflammatory  affection,  the  temper- 
ature will  rise  to  a  greater  height  than  the  local  process  alone  would 
warrant.  This  is  the  case  with  suppurative  inflammation  of  the  middle 
ear.  This  organ  must  always  be  examined  in  cases  of  sudden  rise  of 
temperature.  The  same  active  febrile  reaction  will  take  place  in  osteo- 
myelitis and  in  mastoid  abscess.  The  associate  signs  point  to  the  true 
nature  of  the  affection,  although  it  must  be  confessed  that  in  both  the 
symptoms  are  often  obscure  in  the  beginning. 

2.  In  typhoid  fever  the  temperature  rises  in  a  characteristic  way. 
It  ascends  by  successive  evening  rises,  followed  by  morning  remissions, 
until  it  reaches  the  maximum  at  about  the  end  of  the  first  week. 

The  Significance  of  the  Fastigium.  In  typhoid  fever  the 
course  of  the  fastigium  is  of  characteristic  significance.  From  the  end 
of  the  first,  throughout  the  second  week,  and  sometimes  longer,  the 
fever  is  of  the  continued  type.  Subsecp;iently  during  the  third  week 
or  later,  morning  remissions  set  in,  the  temperature  for  a  time  still 
rising  to  the  former  height  in  the  evening.  Then  the  morning  remis- 
sions become  more  decided,  the  temperature  not  rising  as  high  in  the 
evening,  and  so  gradually  the  temperature  sinks  to  and  below  normal. 
This  course  of  the  temperature  in  typhoid  fever  is  very  far  from  being 
invariable;  it  is  modified  by  indiscretions  on  the  part  of  the  patient 
or  his  attendants,  and  by  the  necessities  of  antipyretic  or  other  treat- 
ment; nevertheless,  the  gradual  onset  of  the  fever  and  its  long  dura- 
tion are  sufficiently  common  to  make  them  of  great  value  in  diagnosis, 
as,  with  the  exception  of  tuberculosis,  there  is  hardly  any  other  disease 
in  which  a  continued  fever  exists  for  two  or  three  weeks  apart  from 
local  inflammation  or  suppuration. 

The  Significance  of  Defervescence.  In  the  self-limited  dis- 
eases there  is  a  period  when  defervescence  should  take  place.  If  it 
docs  not,  this  fact  indicates  that  the  case  is  one  of  a  greater  degree  of 
gravity  than  usual,  or  that  there  is  a  complication.  A  continuance  of 
the  fever,  the  persistence  of  the  fastigium  beyond  the  usual  period,  is 


114 


GENERAL  DIAGNOSIS. 


usually  significant  of  a  complication.  In  measles  the  complication  is 
usually  pneumonia.  This  may  take  place  after  the  disease  has  devel- 
oped, and  may  be  the  cause  of  the  unusual  rise  in  temperature.  In 
scarlatina  it  may  indicate  acute  nephritis,  or  inflammation  of  any  of 
the  serous  membranes,  particularly  the  pericardium  or  endocardium. 
Persistence  of  the  fastigium  of  typhoid  fever  after  the  period  at  which 
it  should  decline,  if  the  patient  is  well  nursed  and  properly  fed,  usually 
indicates  the  occurrence  of  an  inflammatory  complication  Irom  the  orig- 
inal or  a  new  infection,  or  the  development  of  tuberculosis.  In  the 
latter  condition  the  fever  is  more  likely  to  develop  during  the  afebrile 
period,  the  convalescence.  Of  the  inflammatory  complications,  phlebitis 
and  glandular  and  bone  inflammations  are  likely  to  cause  persistence  of 
fever  after  the  normal  period. 


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The  Significance  of  a  Sudden  Fall  or  of  Subnormal  Tem- 
perature. A  sudden  fall  of  temperature  in  a  person  who  has  pre- 
viously had  high  fever  signifies  the  crisis  if  the  time  for  that  event  has 
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perforation,  or  if  peritonitis  has  developed.  It  must  not  be  confounded 
with  the  sudden  falls  of  temperature  that  occur  in  the  typhoid  fever  of 
children,  corresponding  to  the  onset  of  convalescence.  These  occur 
earlier  in  the  period  of  the  disease  than  with  adults. 

The  Diagnostic  Significance  of  the  Type  of  the  Feaek. 
Intermittent  Fever.  The  temperature-range  has  been  observed  for  a 
number  of  days  and  an  intermittent  type  of  fever  ascertained  to  be 
present.  The  representative  of  the  type  is  seen  in  malaria,  but  it  is 
simulated  by  a  number  of  conditions  :  (1)  In  certain  cases  of  typhoid 
fever  and  of  relapsing  fever  the  type  is  intermitting  or  paroxysmal. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


115 


The  same  type  of  fever  is  seen  (2)  in  suppuration,  particularly  if  the 
pus  is  confined,  although  in  brain-abscess  the  temperature  may  be 
normal  or  subnormal;  (3)  in  infectious  endocarditis;  (4)  in  tuberculosis. 
a.  It  may  occur  in  the  earlier  stages  of  tuberculosis.     The  primary 


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116 


GENERAL  DIAGNOSIS. 


it  may  also  occur  when  there  is  suppuration  in  the  genito-urinaiy  tract. 
(8)  Hepatic  intermitting  fever  is  a  form  of  frequent  occurrence  and  of 
great  diagnostic  importance.  It  may  be  due  to  (a)  gall-stones  some- 
where in  the  biliary  ducts,  usually  with  obstruction;  (b)  to  suppuration 
in  the  canal,  with  or  without  obstruction;  (c)  to  obstruction  of  the 
biliary  passages  by  external  pressure  without  suppuration;  (d)  to  in- 
flammatory affections  of  the  liver,  as  abscess,  and  forms  of  cirrhosis. 
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mittent fever  may  also  attend  the  prolonged  use  of  morphine. 

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Pneumonia.    Sudden  rise.    Termination  by  crisis.    Pseudo-crisis  also  seen. 

Of  the  above-mentioned  varieties  of  paroxysmal  or  intermitting 
fever,  those  of  the  most  common  occurrence  are  due  to  suppuration, 
pyaemia,  to  infectious  endocarditis,  to  tuberculosis,  and  to  hepatic  dis- 
order. In  this  class  of  cases,  in  addition  to  the  paroxysmal  rise  in 
temperature,  rigors  and  sweating  frequently  precede  and  follow  the 
paroxysm,  as  in  cases  of  malarial  intermittent  fever.  The  diagnosis 
from  true  intermittent  fever  can  be  established  at  once  by  an  examina- 
tion of  the  blood,  which  reveals  in  the  latter  the  plasmodia  of  Laveran. 

Remittent  fever.  Fever  of  a  remittent  type  occurs  in  many  of  the 
conditions  in  which  intermittent  fever  is  present.  It  is  characteristic 
of  one  of  the  forms  of  malaria.  It  is  most  frequently  encountered  in 
tuberculosis  of  the  lungs.  The  remissions  usually  occur  in  the  morn- 
ings, but  the  order  may  be  reversed.  The  same  type  of  fever  is  met 
with  in  puerperal  fever,  pyaemia,  and  septicaemia,  and  in  local  suppura- 
tions, such  as  abscess  of  the  liver  and  empyema.  A  continued  fever 
may  be  made  to  resemble  a  remittent  by  antipyretic  treatment,  on 
account  of  which  abnormal  remissions  in  the  temperature  take  place. 


THE  DA  TA  OB  TAIN  ED  B  Y  OB  SEE  VA  TION.  117 

Remissions  characterize  the  decline  of  the  continued  fevers,  particu- 
larly typhoid,  during  the  period  of  lysis. 

Continued  fever.  Continued  fever  is  met  with  in  lobar  pneumonia, 
tvphoid  fever,  typhus  fever,  erysipelas,  and  tuberculosis.  In  acute 
lobar  pneumonia  the  temperature  rises  rapidly,  and  in  a  few  hours  from 
the  initial  chill  reaches  103°  or  105°.  The  morning  and  evening 
temperatures  vary  but  little,  usually  not  more  than  one  or  two  degrees, 
until  a  crisis  occurs  in  from  four  to  eight  days.  The  temperature  then 
falls  to  or  slightly  below  normal,  and  does  not  rise  again.  (See 
Fig.  10.) 

A  marked  remission  in  the  fever  sometimes  occurs  on  the  fourth  day, 
before  the  actual  crisis  ;  the  temperature  falls  to  100°,  and  rises  again 
to  103°  or  104°,  remaining  at  that  level  for  twenty-four  or  forty-eight 
hours,  when  the  true  crisis  occurs.  The  first  fall  is  known  as  the 
pseudo-crisis.  The  tall  of  temperature  or  defervescence  (crisis)  may 
be  completed  within  a  few  hours. 

Diagnostic  Significance  Depending  upon  Age  and  Sex.  The 
diagnostic  significance  of  a  high  febrile  change  is  not  so  great  in  chil- 
dren as  in  adults.  That  is,  the  high  temperature  is  not  so  important, 
inasmuch  as  children  are  liable  to  have  sudden,  excessive  increase  of 
temperature ;  and  a  higher  temperature  may  persist  in  children  without 
the  deleterious  effects  upon  the  tissues  which  are  noticed  in  adults. 
In  women  of  nervous  temperament  the  temperature  is  also  likely  to 
rise  to  a  great  height  without  adequate  cause  or  serious  result. 

The  General  Musculature.  The  state  of  the  muscles  must  always 
be  learned.  It  has  been  referred  to  in  the  discussion  on  emaciation. 
A  few  words  more  seem  necessary.  It  must  be  remembered  that  a  per- 
son can  be  obese  and  yet  have  poor  muscular  development,  or  have  little 
fat  and  fair  muscle.  General  lack  of  muscular  development  or  mus- 
cular weakness  is  an  important  sign  of  malnutrition,  and  may  explain 
the  nature  of  many  symptoms.  The  muscular  weakness  can  be  ap- 
proximated by  the  degree  of  firmness  of  the  muscle.  Weakness  of  the 
muscles  of  the  spine,  with  resulting  curvature,  or  inability  to  keep  the 
erect  posture,  is  sufficient  cause  for  the  occurrence  of  neuralgic  pains  in 
the  course  of  related  nerve-trunks,  and  for  the  displacement  of  organs 
within  the  thorax  or  abdomen,  which  often  causes  functional  disturb- 
ance. Various  uterine  displacements  and  functional  disorders  may  be 
mitigated  by  toning  up  the  nutrition  of  the  muscles  of  the  trunk. 
Forms  of  indigestion,  sluggishness  of  secretions,  particularly  of  the 
bowels,  follow  in  the  wake  of  debilitated  muscle  and  pass  away  as 
such  muscles  gain  tone.  It  may  be  that  the  indigestion  has  not  taken 
place  because  the  muscles  are  weak,  although  in  a  measure  there  is 
relation  between  them;  but  the  weak,  flabby  muscles  are  pronounced 
indications  of  a  state  of  the  system  which  may  develop  indigestion. 
The  detection  of  muscular  deficiency  leads  to  correct  lines  of  treatment. 
Atrophy  of  muscles  occurs  because  of  disuse,  because  of  sedentary 
occupation,  or  of  a  life  of  ease  and  luxury  with  improper  nutrition. 
It  is  sure  to  follow  improper  assimilation  in  its  most  prominent  form, 
as  >ccn  in  anorexia,  nervosa. 


118  GENERAL  DIAGNOSIS. 

General  Abnormal  Vital  Conditions.  UNCONSCIOUSNESS;  Fits, 
oe  Seizures;  Collapse;  Shock.  Impairment  of  the  consciousness 
of  the  individual  and  fits  are  readily  recognized.  The  two  often  go 

hand-in-hand,  but  in  some  instances,  as  in  fainting-fits,  consciousness 
is  not  lost.  The  following  list  includes  the  various  forms  with  their 
associate  phenomena.  Only  those  are  mentioned  which  occur  instanta- 
neously. For  their  symptomatology  and  diagnosis  the  appropriate 
sections  on  special  diagnosis  must  be  consulted. 

I.    Uconsciousne.ss  : 

1.  Syncope.  The  face  is  pale  but  calm,  the  pulse  feeble  or  impercep- 
tible, the  extremities  cool;  nausea  or  hurried  breathing  may  precede. 
The  breathing  is  quiet  in  the  attack.  The  pupils  respond  to  light. 
]STo  pain.     (See  Heart  Disease. ) 

2.  Apoplexy.  (Spasm  is  sometimes  associated.)  Head-pain,  con- 
gested lace,  hemiplegia,  facial  palsies,  pupils  irregular  and  irresponsive, 
cornea  not  sensitive,  incontinence  of  urine;  pulse  strong,  full;  arteries 
hard. 

II.  Fits.  1.  Epilepsy.  (1)  "  Haut  mal :"  aura,  convulsions;  (a) 
tonic,  respiratory  muscles  affected,  face  livid,  stupor  afterward;  (6) 
clonic,  tongue  bitten,  stupor  follows.  (2)  "  Petit  mal :"  pallor  sudden, 
no  convulsions. 

2.  Infantile  convulsions.  Usually  reflex  from  indigestion;  may  be 
the  onset  of  a  specific  fever,  or  due  to  high  temperature. 

3.  Puerperal  convulsions.  Headache,  amaurosis,  oedema,  suppressed 
and  albuminous  urine;  clonic  convulsions,  tongue  bitten,  complete  coma. 
(See  Urseniia.) 

4.  Urosmia.  Unilateral  or  bilateral  clonic  convulsions.  (See  Renal 
Disease.) 

5.  Alcoholism,  opium,  and  sunstroke. 

6.  Organic  brain  diseases  (syphilis,  tumor,  softening,  etc.). 

7.  Fits  with  partial  or  no  loss  of  consciousness.  Hystero-epilepsy, 
focal  or  Jacksonian  epilepsy,  hysteria,  cerebral  embolism,  thrombosis, 
or  hemorrhage,  spasms  of  various  kinds. 

8.  Fits  with  vertiginous  movement.  The  forms  of  vertigo  are 
gastric,  aural  and  labyrinthine  (Meniere's,  also  paroxysmal),  ocular, 
cerebellar,  from  congestion  of  the  brain  (reflex),  epileptic. 

III.  Collapse.  Collapse  may  occur  in  a  person  in  apparent  health 
and  be  the  first  indication  of  disease,  as  in  rupture  of  a  large  blood- 
vessel, causing  internal  hemorrhage.  Or  it  may  occur  in  the  course 
of  disease,  as  typhoid  fever,  when  intestinal  hemorrhage  takes  place. 

The  symptoms  are  those  of  prostration,  with  partial  loss  of  conscious- 
ness; or  the  mind  is  perfectly  clear.  The  face  is  pale,  pinched,  and 
bathed  with  perspiration  (see  Hippocratic  Facies).  The  skin  is  cool 
and  clammy.  The  hands  are  cold.  The  skin  is  wrinkled.  The  eyes 
are  sunken  and  encircled  by  dark  rings.  The  voice  is  weak  or  sup- 
pressed. The  pulse  is  rapid  and  thready,  or  may  be  absent  at  the 
wrists.  The  heart-sounds  are  indistinct.  The  temperature  falls.  The 
respiration  may  be  hurried,  or  shallow,  sighing,  and  gasping.  The 
urine  is  scanty  or  may  be  absent.  Collapse  is  due  to  hemorrhage, 
external  or  internal;  to  perforation  of  abdominal  viscera,  to  peritonitis, 


THE  DATA  OBTAINED  BY  OBSERVATION.  119 

to  excessive  watery  discharge,  as  in  cholera  or  serous  purging.     It 
may  be  due  to  pernicious  malarial  fever.      Coma  attends  this  form. 

IV.  Shock  is  a  condition  in  which  the  vital  powers  are  blunted  or 
stunned,  with  or  without  mental  terror  or  anxiety.  It  is  likely  to  be 
seen  in  injury,  surgical  operation,  hemorrhage,  angina  pectoris,  severe 
pain  from  any  cause,  any  sudden  cerebral  or  spinal  lesion,  undue 
mental  and  emotional  strain.  Its  presence  points  to  a  grave  antece- 
dent condition,  near  or  remote.     The  symptoms  are  those  of  collapse. 

B.     Local  Examination  of  the  Exterior. 

The  appearance  and  expression  of  the  face  are  observed,  as  well  as 
the  shape  and  size  of  the  head  and  the  carriage.  Abnormalities  must 
be  noted  and  local  areas  about  the  iace,  as  the  eye,  nose,  and  ear,  par- 
ticularly inspected.  Passing  from  the  head  downward,  the  neck  and 
then  the  extremities  are  to  be  carefully  examined,  independently  of 
the  skin.  After  that  the  bones,  joints,  and  muscles  should  be  studied 
in  regular  order. 

The  Face  and  its  Expression.  (See  Nose  and  Mouth  in  respec- 
tive chapters  on  special  diagnosis.)  The  face  is  a  mirror  in  which  are 
reflected  all  degrees  of  ill  health,  from  that  which  amounts  only  to  tem- 
porary indisposition  and  depression  up  to  the  gravest  cachexia.  The 
iace  reflects  also  the  degree  of  intelligence  of  the  patient  and  his  mental 
condition  at  the  time,  as  well  as  his  emotions,  and,  in  a  large  measure, 
his  character.  The  face  is  usually  a  pretty  good  index  of  the  temper 
of  the  individual;  benevolence,  amiability,  and  purity  are  written  as 
plainly  on  some  faces  as  anger,  lust,  dishonesty  on  others. 

All  varieties  of  mental  aberration  are  reflected  in  the  face;  the  sus- 
picious, at  times  revengeful,  look  of  the  delusional  monomaniac;  the 
wild  look  and  excited  manner  of  the  maniac;  the  plaintive,  depressed, 
injured  look  of  melancholia;  the  vacant,  listless,  peaceable,  animal- 
like look  of  dementia — a  look  which  changes  to  animation  only  at  the 
sight  of  food  or  some  coveted  luxury.  All  these  expressions  come  to 
be  recognized  very  readily  by  those  who  see  much  of  the  insane. 

The  lace  frequently  affords  us  valuable  information  concerning  the 
health,  habits,  and  temperament  of  the  individual.  Everyone  is 
familiar  with  the  bright  eye  and  animated  countenance  of  a  friend 
which  lead  us  to  say,  "  You  are  looking  very  well  to-day,"  and  with 
that  slight  pallor,  diminished  clearness  of  the  conjunctiva,  with  per- 
haps a  dark  circle  under  each  eye,  which  lead  us  to  infer  that  he  is 
depressed  or  has  passed  a  sleepless  night.  The  lace  also  gives  unmis- 
takable evidence  of  alcoholism  by  its  bloated  appearance,  injected  or 
glassy  eye,  dull  expression,  and  nervousness  when  the  patient  is  ad- 
dressed suddenly. 

Full-blooded  persons,  disposed  to  endarterial  changes,  frequently  as 
the  result  of  gout,  often  have,  at  a  little  distance,  the  ruddy  appearance 
of  blooming  health.  Closer  inspection,  however,  shows  that  the  ruddy 
color  is  due  to  a  dilated  or  congested  condition  of  the  minute  blood- 
vessels.     This  condition,  when  associated  with  high   tension   in   the 


120  GENERAL  DIAGNOSIS. 

arteries  and  accentuation  of  the  aortic  second  sound,  is  highly  sugges- 
tive of  chronic  nephritis.      (For  color,  see  Skin.) 

Moreover,  the  face  tells  of  the  presence  or  absence  of  pain,  and,  to 
a  certain  extent,  of  its  character.  Everyone  has  witnessed  the  sudden 
contraction  of  the  brow  and  eyelids,  and  the  involuntary  sucking  in  of 
the  breath  when  someone  has  bitten  upon  a  tender  tooth.  Other  faces 
bear  the  imprint  of  long-continued,  more  or  less  constant  suffering. 
According  to  Eustace  Smith,  pain  in  the  head  in  children  is  indicated 
by  contraction  of  the  brows;  pain  in  the  chest,  by  sharpness  of  the 
nostrils;  and  in  the  bellv,  by  a  drawing  of  the  upper  lip.  (See  Pain, 
p.  35.). 

It  will  be  seen  that  the  expression,  the  color,  and  the  outline  of  the 
face  are  valuable  indications  of  disease. 

The  master  mind  in  clinical  medicine,  the  late  Austin  Flint,  Sr., 
tersely  described  the  various  appearances  of  the  face  in  disease,  with 
their  clinical  significance,  as  follows  : 

The  Facies  of  Kenal  Disease.  In  some  cases  of  acute  albumi- 
nuria and  of  chronic  parenchymatous  nephritis — the  large  white  kid- 
ney of  Bright — puffiness  of  the  face  from  oedema,  with  notable  pallor, 
renders  the  aspect  highly  diagnostic. 

The  Malarial  Facies.  Pallor  of  the  face,  sallowness,  and  slight 
puffiness,  if  renal  disease  be  excluded,  point  to  malarial  disease. 

The  Facies  of  Carcinoma.  Notable  ansemia,  a  waxy  or  straw- 
colored  complexion,  and  more  or  less  emaciation,  in  combination,  render 
the  aspect  marked  in  some  cases  of  malignant  disease.  In  a  patient 
over  forty  years  of  age  this  aspect  has  considerable  diagnostic  import, 
although  it  is  by  no  means  always  present  when  malignant  disease 
exists. 

The  Typhoid  Facies.  In  the  middle  and  later  periods  of  typhoid 
fever  the  countenance  is  often  dull,  besotted,  expressionless.  This 
facies  may  be  present  in  the  typhoid  state,  which  is  incident  to  diseases 
other  than  typhoid  fever  ;  e.  g. ,  pneumonia.  Coexisting  with  a  dusky 
hue  of  the  skin  and  congestive  redness  of  the  conjunctiva,  it  distin- 
guishes typhus,  as  contrasted  with  typhoid  fever. 

The  Facies  of  Acute  Peritonitis.  The  upper  lip  raised  so  as 
to  expose  the  front  teeth  gives  an  aspect  which  characterizes,  in  a 
certain  proportion  of  cases,  acute  peritonitis.  It  is  often  wanting,  but 
when  present  it  is  strongly  diagnostic. 

The  Facies  of  Acute  Pneumonia  and  Hectic  Fever.  Cir- 
cumscribed redness  of  one  or  both  of  the  cheeks,  with  abruptly  defined 
borders,  is  diagnostic  of  acute  pneumonia.  If  it  be  observed  in  a  case 
of  chronic  pulmonary  disease,  it  denotes  the  so-called  hectic- fever,  and 
is  a  sign  of  phthisis. 

The  Facies  of  Exophthalmic  Goitre.  Projection  of  the  eye- 
balls, giving  to  the  face  a  remarkably  staring  and  sometimes  ferocious 
expression,  conjoined  with  enlargement  of  the  thyroid  body  and  fre- 
quency of  the  pulse,  is  distinctive  of  the  affection  known  as  exophthal- 
mic goitre — Graves's  disease  and  Basedow's  disease. 

The  Choleraic  Facies.  In  the  collapsed  stage  of  cholera  the 
face  is  contracted,  sometimes  wrinkled;  the  cheeks  are  hollow,  the  eyes 


THE  DA TA  OB TAINED  B  Y  OBSEB  VA  TION.  1 21 

sunken,  the  skin  is  livid,  and  the  expression  denotes  indifference.  This 
combination  of  traits  is  quite  distinctive.  They  are,  however,  to  a 
certain  extent  combined  in  the  state  of  collapse  which  occurs  in  some 
cases  of  pernicious  intermittent  fever,  and  in  other  pathologic  connec- 
tions. 

The  Hippocratic  Facies.  This  facies  denotes  the  moribund 
state.  The  skin  is  pale,  with  a  leaden  or  livid  hue;  the  eyes  are  sun- 
ken, the  eyelids  separated,  and  the  cornea  loses  its  transparency;  the 
nose  is  pinched,  and  the  eyes  are  contracted;, the  temples  are  hollow, 
and  the  lower  jaw  drops.  Hippocrates  described  this  facies  in  graphic 
terms,  and  the  name  Hippocratic  has  ever  since  been  used  to  desig- 
nate it. 

The  Face  in  Children.  Inspection  is  even  more  important  in 
the  case  of  children  than  in  adults.  The  pale,  pinched,  weazened  face 
of  some  babies  who  have  snuffles,  ulcers,  or  striated  lines  at  the  corners- 
of  the  mouth,  and  look  prematurely  aged,  with  prominent  forehead 
and  a  depressed  nasal  bridge  and  retrousse  tip,  characterizes  inherited 
syphilis.  In  older  subjects  the  undeveloped  face  and  skull  are  striking. 
In  rickets  the  head  is  unusually  large  with  flattened  vertex,  projecting 
forehead,  and  open  fontanelle.  In  hydrocephalus  the  head  becomes 
very  much  enlarged,  the  eyes  prominent,  the  bones  of  the  face  remain- 
ing small,  the  expression  vacant  (see  p.  125).  In  adenoid  disease 
of  the  pharynx,  with  tonsillar  hypertrophy,  the  dull  apathetic  expres- 
sion, with  the  thickened  lips,  the  small  nasal  orifices,  and  the  gaping 
mouth  are  characteristic.  In  measles  the  red,  swollen  face,  the 
reddened,  weeping  eyes,  and  running  nose  make  a  very  striking  picture. 
An  irritating,  excoriating  discharge  from  the  nose  in  a  child  may  indi- 
cate the  existence  of  a  nasal  diphtheria. 

The  Face  in  Nervous  Disease.  The  face  often  tells  of  the 
existence  of  some  organic  nervous  disorders. 

In  peripheral  facial  palsy  the  paralyzed  side  of  the  face  has  a  staring, 
vacant  expression,  owing  to  the  fact  that  the  eyelids  are  motionless. 
The  angle  of  the  mouth  on  the  affected  side  is  depressed.  The  whole 
paralyzed  side  is  devoid  of  wrinkles,  has  a  smoothed-out,  glazed  appear- 
ance; tears  flow  over  the  cheeks,  and  saliva  dribbles  from  the  corner 
of  the  mouth.  The  contrast  with  the  normal  side  is  most  marked 
when  the  patient  smiles  or  frowns. 

In  glosso-labial  palsy  there  is  progressive  palsy,  with  tremulousness 
of  tongue  and  lips;  progressive  failure  of  articulation,  and  dribbling 
of  saliva.  Sometimes  the  patient  is  able  to  open  the  lips,  but  unable 
to  close  them  without  the  aid  of  the  hand.  In  paralysis  agitans  the 
mask-like  expression  of  immobility  has  been  described  as  Parkinson's 
mask. 

A  slow,  hesitating,  thick  manner  of  speaking,  with  a  tendency  to 
slur  the  labial  and  lingual  consonants,  when  associated  with  irregularity 
of  the  pupils,  slight  tremulousness  of  the  lips,  and  the  loss  of  the  fine 
adjustment  of  other  muscular  movements,  such  as  writing,  is  very  sug- 
gestive of  general  paralysis  of  the  insane,  especially  when  the  condition 
develops  in  a  middle-aged  man. 

Facial  hemiatrophy  is  a  peculiar  affection,  characterized  by  progres- 


122  GEXERAL  DIAGNOSIS. 

sive  wasting  of  the  bones  and  soft  tissues  of  one  side  of  the  face.  The 
disease  is  rare;  it  begins,  as  a  rule,  in  childhood,  but  may  develop  in 
later  life.  The  local  change  is  diffuse,  in  some  instances,  however,  it 
slowly  spreads  from  a  spot  in  the  skin,  involving,  in  succession,  the 
tissues  underneath.  The  skin  changes  in  color  and  the  hair  falls  out. 
The  eye  is  sunken  on  the  affected  side  on  account  of  wasting  of  the 
tissues  of  the  orbit.  The  bone  of  the  upper  jaw  atrophies  to  a  more 
advanced  degree  than  the  other  bones  which  undergo  wasting.  Because 
of  the  wasting  of  the  alveolar  processes  the  teeth  become  loose  and  fall 
out.  The  wasting  is  sharply  limited  by  the  middle  line.  The  disorder 
is  easily  recognized.  The  patient  looks  as  if  the  i'ace  were  made  up 
of  two  halves  from  different  persons.  It  must  not  be  mistaken  for  the 
facial  asymmetiy  that  is  associated  with  congenital  wry-neck.  The 
contraction  of  the  sterno-mastoid  muscle  from  birth  distinguishes  the 
affection. 

(For  spasm  and  contraction  of  the  muscles  of  the  face,  see  Disease 
of  Cranial  Xerves.) 

The  outline  of  the  face  and  any  change  in  the  shape  of  the  head 
should  next  be  observed.  Both  changes,  as  seen  in  rickets,  have  been 
described.  The  striking  changes  in  acromegalia,  myxoedema,  and  oste- 
itis deformans  have  also  been  described  in  sections  referring  to  these 
affections.  In  leprosy  the  face  is  characteristic  ;  the  leonine  counte- 
nance— -fades  leontina — is  the  result  of  the  tuberous  outgrowths  about 
the  eyes  and  forehead. 

Enlargement  of  the  Face.  Swelling.  Other  changes  in  the 
outline  of  the  face  and  skull  are  significant.  The  face  is  swollen  and 
deformed  in  erysipelas  and  smallpox,  and,  to  a  moderate  degree,  in 
measles.  The  specific  eruption  serves  to  distinguish  each  one.  The 
pufnness  of  the  eyelids  and  general  swelling  of  the  face,  which  arise 
in  the  course  of  Bright' s  disease,  will  be  referred  to.     (See  (Edema, ) 

In  mumps  the  swelling  is  characteristic.  It  usually  begins  on  one 
side.  The  swelling  of  the  parotid  gland  is  observed  in  front  of  the 
ear,  then  it  extends  below  and  around  it  and  behind  the  ramus  of  the 
jaw.  Unless  there  is  much  collateral  oedema,  the  outline  of  the  gland 
is  preserved.  The  lymphatics  may  or  may  not  be  swollen.  The  gland 
is  tender  and  boggy,  not  indurated.  Viewing  the  face  from  the  front, 
the  midlateral  aspects  are  seen  to  bulge.  The  ears  stand  out  from  the 
head. 

(Edema  of  the  face  occurs  in  trichinosis.  It  occurs  at  two  periods 
in  the  course  of  the  disease.  It  is  seen  in  the  eyelids  in  the  begin- 
ning of  the  disease,  and  disappears  after  a  few  days.  Later  in  the 
disease  it  returns,  with  pain,  tension,  and  restriction  of  the  move- 
ment of  the  eye-muscles.  The  oedema  may  be  due  to  infection  of 
the  muscles  by  the  parasite  or  may  be  of  vasomotor  origin. 

Hair.  The  hair  often  indicates  the  state  of  the  nutrition  of  the 
individual.  Changes  in  it  may  be  significant  of  syphilis  or  other  inter- 
nal morbid  processes.  The  abnormal  growths  and  changes  in  the 
texture  due  to  local  parasitic  disease  will  not  be  referred  to.  Undue  and 
rapid  falling  out  of  the  hair  in  patches,  known  as  alopecia,  is  indicative 


THE  DATA  OBTAINED  BY  OBSERVATION.  123 

of  syphilis  and  of  profound  intoxication  by  the  virus  of  this  disease. 
The  hair  can  be  pulled  out  in  large  masses  without  difficulty  or  pain. 
This  tailing  of  the  hair  must  not  be  confounded  with  the  excessive 
falling  out  which  takes  place  in  the  convalescence  of  acute  disease, 
particularly  of  typhoid  fever,  nor  with  that  following  an  attack  of 
gout  or  erysipelas. 

Color  of  the  Hair.  Obscure  paralysis  or  anaemia  may  be  ex- 
plained by  noting  if  the  hair  is  artificially  colored.  Lead  and  other  poi- 
sonings have  repeatedly  arisen  from  the  use  of  hair-dyes.  Other  changes 
in  the  color  are  often  significant.  Early  gray  hair  may  go  hand-in- 
hand  with  premature  endarteritis.  The  term  ' '  canities ' '  is  applied 
to  the  diminished  development  of  pigment.  Premature  gray  color 
in  defined  patches  occurs  in  nerve-lesions,  as  paralysis  of  one  of  the 
branches  of  the  fifth  pair,  and  is  a  trophic  change.  Sudden  change 
in  the  color  of  the  hair,  usually  to  gray,  takes  place  at  times  under 
the  influence  of  fright,  mental  anxiety,  or  deep  emotion. 

' '  Green ' '  hair  is  seen  in  brass-founders  and  workers  in  copper-mines ; 
"  blue"  hair  in  laborers  in  cobalt-mines  and  persons  employed  in  the 
manufacture  of  indigo.  Chemicals  applied  to  the  hair  change  its  color 
— peroxide  of  hydrogen  bleaches  the  hair,  pyrogallic  acid  turns  it 
black.  Drugs  administered  internally,  as  jaborandi  and  its  alkaloid, 
change  the  color  to  dark  hues. 

Local  Affections  of  the  Skin  of  the  Face.  Comedones  are  pap- 
ular elevations  with  a  central  pit  of  dark  color,  due  to  accumulated 
dirt.  Milium  from  obliteration  of  the  ducts  consists  of  small,  rounded 
papules  of  whitish  color.  They  are  common,  but  are  not  of  special 
significance.  In  molluscum  the  entire  sebaceous  gland  is  distended  bv 
altered  secretion.  Acne  is  a  papular  affection,  inflammatory  in  char- 
acter, appearing  at  the  seat  of  the  comedones,  and  may  be  indurated 
or  pustular.  In  the  latter  instance  pits  are  left  behind.  It  is  com- 
monly seen  in  gouty  subjects,  in  chronic  dyspepsia,  in  uterine  disorder, 
and  in  liver-disturbance. 

The  sebaceous  glands  of  the  skin  of  the  face  merit  but  a  passing 
notice.  Deficiencies  or  excesses  of  secretion,  or  alteration  of  it,  are 
usually  due  to  local  causes.  Excessive  secretion  of  sebaceous  matter, 
known  as  seborrhoea,  or  steatorrhoea,  is  seen  in  two  forms.  First,  with 
oily  exudation;  second,  with  drying  of  the  secretion  and  the  formation 
of  crusts.  It  may  be  more  pronounced  in  strumous  subjects.  The 
opposite  condition,  or  asteatodes,  is  seen  in  wasting  diseases,  particu- 
larly diabetes,  and  in  xeroderma  and  ichthyosis. 

The  Cranium.  The  change  of  shape  in  general  bone-affections  has 
been  referred  to  (see  preceding  pages  for  rickets,  acromegalia,  osteitis 
deformans).  The  peculiar  shape  due  to  congenital  deformities,  or 
deficiency  of  the  bone-plates,  is  not  within  the  province  of  this  work. 
Examination  is  made  by  palpation  as  well  as  by  inspection.  By  the 
former  the  fontanelles  arc  examined,  the  presence  of  bosses  and  loose 
plates  adjacent  to  the  sutures  detected.  The  term  craniotabes  is  usually 
applied  to  this  condition  in  early  rickets. 


124 


GENERAL  DIAGNOSIS. 


Fontanelles.  Prominence  or  fulness  is  seen  in  hydrocephalus  and 
other  brain  affections  in  which  there  is  an  increase  of  internal  pressure. 
Depression  of  the  fontanelles  occurs  in  general  atrophy,  marasmus,  and 
in  wasting  diseases  generally.  It  is  present  in  collapse,  and  is  of  prog- 
nostic omen.  The  fontanelles  are  neither  prominent  nor  depressed  in 
rickets,  a  point  of  distinction  between  this  affection  and  hydroceph- 
alus or  enlargement  from  other  internal  causes.  The  bones  of  the 
cranium  may  be  thickened;  they  may  be  the  seat  of  periostitis,  of 
necrosis,  and  caries.  Necrosis  and  caries  of  the  frontal  bone  is  almost 
pathognomonic  of  syphilis.  Necrosis  of  the  jaw  bone  belongs  to  phos- 
phorus-poisoning.     The  mastoid  and  petrous  portions  of  the  temporal 

Fig.  11. 


Congenital  hydrocephalus.    Female,  aged  seventeen.    (The  thinness 
of  the  hair  could  not  be  represented.) 

bone  should  be  examined  in  many  affections.  The  symptoms  that 
should  call  our  attention  to  these  bones  are  pain  and  tenderness  over 
the  mastoid,  rigors,  and  fever,  with  the  symptom  of  thrombosis  of  the 
cerebral  sinuses,  pain  in  the  head,  convulsions,  and  strabismus.  Ex- 
amination in  this  region  should  extend  to  the  occipito-atlantal  articu- 
lation. Disease  of  this  articulation,  and  particularly  tubercular  disease, 
causes  stiffness  of  the  neck,  or  falling  forward  of  the  head.  On 
account  of  the  stiffness,  associated  with  difficulty  of  deglutition  and 
pain,  the  writer  has  seen  it  mistaken  for  retro  pharyngeal  abscess. 


THE  DATA  OBTAINED  BY  OBSERVATION.  125 

The  expression  and  contour  of  the  face  are  of  much  significance  in 
cerebral  disorders. 

Affections  which  cause  an  increase  in  intracranial  pressure  cause, 
also,  striking  changes  in  the  features  and  in  the  cranium,  as  in  hydro- 
cephalus. 

Hydrocephalus.  The  enlargement  of  the  skull  is  very  conspicuous, 
and  the  disproportion  of  the  cranium  to  the  face  is  striking.  The 
cranium  is  rounded  or  globular  in  shape,  and  the  fontanelles  are  seen 
to  be  very  large,  tense,  and  bulging,  and  the  sutures  widely  separated. 
The  disproportion  in  size  between  the  face  and  head  is  increased  by 
the  projection  of  the  anterior  portion  of  the  skull.  The  axis  of  the 
eyes  is  directed  downward,  and  they  are  partly  covered  by  the  eyelids, 
because  of  the  oblique  direction  of  the  orbital  plates.  The  head  is 
supported  with  difficulty;  the  eyeballs  roll  from  side  to  side.  There 
is  frequently  strabismus.  The  skin  is  stretched  tightly  over  the  cra- 
nium, and  the  hair  is  scanty.     (See  Fig.  11.) 

The  enlargement  of  the  head  must  not  be  confounded  with  rickets 
(see  under  Skeleton),  nor  with  enlargement  and  thickening  of  the  bones. 
In  the  former  the  head  is  square  in  shape,  not  globular,  and  1he  ionta- 
nelles,  though  large,  do  not  bulge.  Other  signs  of  rickets  aid  in  the 
distinction.  Gowers  states  that  thickening  of  the  cranial  bones  may 
simulate  hydrocephalus  at  almost  any  age.  He  thinks  it  doubtful 
whether  the  nature  of  the  latter  rare  cases  can  be  ascertained  during 
life.  The  thickening  that  attends  osteitis  deformans  and  acromegalia 
has  been  already  described.  In  leontiasis  ossea  the  head  is  enlarged 
and  the  bones  of  the  cranium  thickened. 

The  Lips.  Color.  The  lips  are  pale  in  aneemia,  and  livid  in  cya- 
nosis from  chronic  lung  or  heart  disease  with  feeble  circulation.  Vesi- 
cles (herpes)  are  apt  to  appear  upon  them  in  common  colds,  in  certain 
febrile  diseases,  particularly  pneumonia,  and  with  many  women  during 
or  immediately  following  menstruation.  A  child  with  hereditary  syph- 
ilis may  show  ugly  fissures,  or  the  scars  which  result  from  them,  at 
the  angles  of  the  mouth.  In  facial  palsy  the  angle  of  the  mouth  ou 
the  paralyzed  side  is  depressed  and  free  from  wrinkles.  In  glosso- 
labial  laryngeal  palsy  the  lips  tremble,  twitch,  and  may  have  to  be 
closed  with  the  fingers  after  they  have  been  opened.  In  general  paral- 
ysis of  the  insane  the  lips  tremble,  and  speech  is  "  thick,"  hesitating, 
and  uncertain,  with  a  tendency  to  elide  syllables  and  slur  the  labial 
consonants. 

The  Eye.  The  eyelids  in  oedema  have  been  described.  The  dropsy 
may  accumulate  during  the  night  in  little  bags  under  the  loMrer  eyelid. 
It  is  seen  in  the  morning  on  rising,  and  disappears  at  night.  (See 
GEdema.)  It  must  not  be  confused  with  the  morning  puffiness  that 
seems  to  be  natural  to  some  individuals,  or  the  swollen  tace  that  suc- 
ceeds a  debauch.  We  sometimes  see  a  peculiar  change  in  the  skin  of 
the  eyelid  due  to  xanthelasma.  Besides  occurring  in  this  situation  it 
involves  the  palms  of  the  hands,  the  flexures  of  the  fingers,  and  the 
inside  of  the  mouth  (see  under  Tongue).     On  the  eyelids  are  seen 


126  GENERAL  DIAGNOSIS. 

slightly  elevated  patches  of  a  yellowish  color,  irregular  in  shape.  They 
are  slightly  sensitive  to  the  touch,  but  not  indurated.  The  cuticle  is 
healthy.  They  are  due  to  oil  deposited  in  the  neighborhood  of  the 
hair- follicles,  in  the  substance  of  the  cutis.  Sometimes  they  are 
arranged  in  the  form  of  tubercles  as  large  as  a  pea. 

Drooping  of  the  eyelids  may  occur  from  paralysis  of  the  third  nerve. 
It  is  known  as  ptosis.  (For  this  and  affections  of  the  oculomotor  and. 
optic  nerve,  see  The  Eye — Nervous  Diseases.) 

The  Open  Eye.  This  is  known  as  lagophthalmos.  It  is  due  to* 
paralysis  of  the  orbicularis  palpebrarum.  It  is  present  more  or  less 
in  exophthalmic  goitre. 

Exophthalmos.  The  eyeball  protrudes  more  or  less  from  the  socket 
in  tumors  of  the  nose  or  orbit.  In  exophthalmic  goitre  both  eyeballs 
protrude,  and  with  the  change  in  the  appearance  of  the  neck  give  to 
/the  patient  the  so-called  ferocious  appearance.  The  protrusion  of  the 
'eyeballs  is  readily  recognized  because  it  is  bilateral.  The  so-called 
Von  Graefe'  s  sign  further  aids  in  the  diagnosis.  This  sign  consists  in 
lagging  of  the  upper  lid  in  movements  of  the  eyeball.  When  the 
patient  looks  down  the  lid  does  not  readily  follow  the  movements  of 
the  ball  downward. 

Stell wag's  sign  is  the  third  ocular  sign  of  significance  in  exoph- 
thalmic goitre.  There  is  undue  exposure  of  the  cornea,  because  of 
retraction  of  the  upper  eyelid.  One  or  all  signs  may,  however,  be 
absent. 

Proptosis  is  also  seen  in  scurvy.  Extravasation  of  blood  takes  place 
between  the  orbital  plate  of  the  frontal  and  its  periosteum;  the  eyeball 
is  pushed  down  thereby.  It  is  associated  with  oedema  and  often  with 
ecchymosis  of  the  lids.  Both  eyes  may  be  displaced  downward  and 
forward;  or  only  one  eye  affected. 

Sunken  Eyes.  Sunken  eyes  are  due  to  atrophy  of  the  fat  of  the 
socket  in  phthisis  or  wasting  diseases.  It  is  most  pronounced  in  the 
sudden  atrophy  that  occurs  in  cholera  from  loss  of  water.  It  is  also 
seen  in  peritonitis  and  collapse  irom  other  causes. 

The  Conjunctivae.  The  conjunctivae  may  be  the  seat  of  inflam- 
mation from  local  causes.  Its  occurrence  in  the  course  of  general  or 
internal  disease  concerns  us.  It  is  often  seen  in  disease  of  the  brain 
or  the  meninges,  and  sometimes  early  in  the  course  of  this  affection. 
In  tuberculous  meningitis  purulent  conjunctivitis  is  of  common  occur- 
rence. Usually  one  side  is  more  inflamed  than  the  other.  Conjunc- 
tivitis is  of  diagnostic  significance,  along  with  other  symptoms,  of 
involvement  of  the  cranial  nerves.  In  measles  conjunctivitis  is  seen 
early.  In  typhus  fever  it  is  a  constant  sign  and  serves  to  distinguish 
the  affection  from  typhoid.  In  yellow  fever  the  mild  conjunctivitis 
causes  the  watery  ferret-eye.  The  conjunctiva  is  tested  with  the  finger 
to  determine  the  degree  of  sensitiveness  of  a  patient  who  is  more  or 
less  unconscious. 

The  Color.  The  normal  color  of  the  ocular  conjunctiva  is  clear 
white.  In  jaundice  it  is  yellow.  It  is  yellow  in  small  areas  from  fat 
in  the  obese  and  age  J.     The  I  at  is  in  cone-shaped  areas.     The  pearly 


THE  DATA   OBTAINED  BY   OBSERVATION.  127 

sclerotic  of  chlorosis,  the  dead-white  color  of  anaemia,  as  in  Bright' s 
disease  and  phthisis,  are  striking  in  these  affections.  The  palpebral 
and  ocular  conjunctivae  are  the  seat  of  hemorrhage  in  epilepsy,  whoop- 
ing-cough, asthma,  and  of  hemorrhagic  infarcts  in  ulcerative  endocar- 
ditis. (See  Disease  of  Cranial  Nerves  for  movements  of  eyeball,  the 
iris,  appearance  of  the  retina,  etc.) 

The  Cornea.  Ulceration  of  the  cornea  is  sometimes  a  trophic  lesion 
due  to  paralysis  of  the  first  branch  of  the  trifacial  nerve.  It  may 
occur  in  paralysis  of  the  eyelid  from  exposure.  Opacities  result  from 
such  ulcerations  and  from  syphilis.  In  congenital  syphilis  the  remains 
of  keratitis  are  frequently  seen.  Arcus  senilis  is  observed  in  the  cir- 
cumference of  the  cornea  at  its  junction  with  the  sclerotic.  It  is  a  distinct 
arc  and  sometimes  a  complete  circle.  The  cornea  is  hazy  and  may 
contain  fat-granules.  The  eyelids  must  often  be  lifted  to  recognize  it. 
Its  edges  are  ill-defined.  In  contradistinction  to  the  true,  Fothergill 
calls  attention  to  the  false  arcus  senilis — a  well-defined  ring  which 
encircles  the  pupil;  the  cornea  in  this  case  is  always  clear  and  the  per- 
son in  good  health,  though  aged.  The  true  arcus  senilis  is  seen  in  the 
gouty,  in  arterial  sclerosis,  and  in  neprhitis.  It  is  an  early  indication 
of  degeneration  of  the  arteries. 

The  Ear.  The  external  ear  should  always  be  examined.  This  is  par- 
ticularly important  in  inflammation  of  the  meninges  and  other  diseases 
of  the  brain.  In  otherwise  unexplainable  cases  of  pyaemia  or  of  pyeemic 
symptoms  (alternating  chills  and  fever)  the  presence  of  discharge  from 
the  ear  should  be  inquired  for,  as  middle-ear  disease  very  frequently 
results  in  inflammation  of  the  mastoid,  and  from  thence  the  sinuses  and 
adjacent  membranes  of  the  brain  become  inflamed;  or  the  ear  suppura- 
tion may  be  the  primary  focus  from  which  general  infection  has  taken 
place.  It  may  not  be  possible  in  all  cases  to  observe  a  discharge.  It 
may  have  diminished  or  disappeared  on  account  of  the  fever.  Tender- 
ness and  oedema  over  the  mastoid,  perforation  or  bulging  of  the  ear- 
drum, as  well  as  other  inflammatory  signs,  point  to  the  occurrence  of 
suppuration  of  the  middle  ear  and  mastoid  cells.  It  must  not  be  for- 
gotten that  a  bloody  discharge  from  the  ear  may  take  place  in  fractures 
of  the  skull.  The  ears  must  also  be  examined  in  cases  of  coma  from 
injury,  or  if  the  origin  of  coma  is  obscure. 

The  External  Ear.  From  the  exterior  of  the  ear  we  derive  but  few 
data  of  diagnostic  significance.  It  is  true,  the  thin  ear  may  show  the 
anaemic  or  chlorotic  hue  more  strikingly  than  other  portions  of  the 
body;  or  the  opposite  condition  may  be  more  vividly  shown.  Hoema- 
toma  amis  is  seen  in  general  paralysis  of  the  insane  and  in  other  forms 
( >f  insanity.  It  is  a  tropho-neurosis.  The  car  is  thickened  and  deformed 
on  account  of  effusion  of  blood  between  the  cartilages  and  the  peri- 
chondrium. It  is  discolored  and  simulates  the  subcutaneous  effusion 
due  to  injury.  Apart  from  color-changes  tophi  are  observed  in  the 
external  ears  of  patients  with  a  gouty  diathesis.  They  are  small,  hard, 
gritty  accretions  seen  in  the  external  ears  along  the  margin,  or  in  the 
depressions.     They  consist  of  urate  of  soda. 

The  power  and  acuteness  of  hearing  must  be  tested.     This  may  be 


128  GENERAL  DIAGNOSIS. 

done  with  the  voice,  with  the  watch,  and  with  the  tuning-fork.  In 
some  cases  the  voice  may  be  easily  heard,  while  the  ticking  of  a  watch 
can  be  distinguished  only  with  great  difficulty.  The  tuning-fork  is  used 
to  determine  whether  deafness  is  due  to  (1)  obstruction  or  (2)  disease 
of  the  internal  ear.  If  it  is  due  to  obstruction,  the  fork  is  heard 
better  on  contact  with  the  skull  than  when  held  close  to  the  ear.  This 
kind  of  deafness  is  always  due  to  disease  of  (1)  the  external  meatus, 
(2)  the  tympanic  membrane  and  middle  ear,  or  (3)  the  Eustachian  tube. 

Deafness  from  internal  ear  disease  may  be  due  to  affections  of  the 
labyrinth,  as  inflammation,  caries,  and  necrosis,  or  of  the  auditory 
nerve.  The  tuning-fork  is  not  heard  on  contact  with  the  skull.  The 
auditory  nerve  may  be  diseased  in  its  course,  or  the  auditory  centre 
may  be  affected.  Tumors,  meningitis,  hemorrhage,  and  infectious 
diseases  may  involve  the  auditory  nerve,  Avhile  the  auditory  centre  is 
affected  by  tumor,  meningitis,  abscess,  and  hemorrhage.  (See  under 
Cerebral  Localization.)  It  must  not  be  forgotten  that  certain  drugs, 
as  quinine  and  the  salicylates,  may  cause  deafness. 

Hysterical  or  functional  deafness  is  recognized  (1)  by  its  association 
with  undoubted  symptoms  of  hysteria;  (2)  by  its  sudden  occurrence 
after  shock,  emotional  disturbance,  or  trauma;  (3)  the  absence  of  a  cause 
in  the  auditory  apparatus  for  the  deafness;  (4)  impairment  of  bone- 
conduction  and  aerial  conduction  to  the  same  degree;  (5)  the  frequent 
coexistence  of  anaesthesia  of  the  pinna  and  external  meatus;  (6)  fre- 
quently recovery  takes  place  suddenly. 

Hysterical  deaf-mutism  is  a  rare  condition  characterized  by  (1)  sudden 
origin;  (2)  absolute  aphasia  and  aphonia;  (3)  absence  of  signs  of  labio- 
glossal  paralysis  and  of  any  paralytic  phenomena  except  hysterical  hemi- 
plegia; (4)  preservation  of  intellectual  faculties  and  power  of  writing; 
(5)  frequent  coexistence  of  hysterical  stigmata;  (6)  usually  rapid  re- 
covery. 

The  Neck.  Inspection  and  palpation  are  employed  to  determine 
the  shape  and  size  of  the  structures.  The  position  of  the  trachea 
and  larynx,  the  seat  and  size  of  the  thyroid  gland,  state  of  the 
lymphatic  glands,  and  the  appearance  of  the  vessels  of  the  neck 
should  be  observed.  The  trachea  and  larynx  occupy  the  median 
line  in  health,  but  may  be  deflected  to  the  right  or  left.  The 
deflection  is  more  readily  noticed  at  the  lower  part  of  the  neck,  and 
can  be  ascertained  by  comparing  its  position  with  the  normal  rela- 
tion to  the  adjacent  muscles.  The  change  in  position  is  due  to 
disease  within  the  thorax.  An  aneurism  or  a  mediastinal  tumor 
may  cause  this  alteration.  In  cases  of  chronic  fibroid  phthisis  the 
trachea  is  pulled  to  the  side  of  the  affected  lung.  "When  the 
respiratory  movement  of  the  larynx  and  trachea  is  excessive  and 
associated  with  dyspnoea  the  source  of  .the  dyspnoea  is  of  laryngeal 
origin.  "When,  on  the  other  hand,  the  movements  are  lessened,  or 
the  organs  remain  fixed,  notwithstanding  violent  efforts  at  respiration, 
the  dyspnoea  is  due  to  disease  in  the  mediastinum,  as  enlargement 
of  the  mediastinal  glands,  or  aneurism  pressing  upon  a  bronchus. 
Tracheal  tugging  may  be  seen,  but  is  usually  determined  by  palpa- 


THE  DATA  OBTAINED  BY  OBSERVATION.  129 

tion.  It  is  particularly  characteristic  of  aneurism  of  the  descending 
portion  of  the  aorta.  The  aneurismal  sac  presses  upon  the  bronchus, 
and,  with  each  pulsation  of  the  vessel,  tugs  or  pulls  downward  upon 
the  trachea,  which  tugging  is  transmitted  to  the  hand.  (See  Diseases 
of  the  Vessels.) 

Thyroid  Gland.  It  may  be  enlarged  or  atrophied.  Atrophy  is 
shown  by  absence  of  fulness,  which  would  otherwise  be  present  in  the 
neck  of  the  individuals  of  the  age  of  the  patient  under  examination. 
(See  Myxoedema  and  Acromegalia.) 

Enlargement  of  the  thyroid  can  be  detected  without  much  diffi- 
culty. It  may  be  limited  to  one  lobe,  or  both  lobes  may  be  affected. 
It  may  vary  in  size  from  a  small  localized  swelling  to  large  masses 
which  fill  the  median  and  lateral  sides  of  the  neck,  pressing  upon  the 
trachea  and  extending  into  the  thorax.  On  palpation  the  swelling  may 
be  soft  or  hard.  In  the  fibrous  forms  the  swelling  is  not  very  large 
and  is  very  much  indurated.  In  the  cystic  forms  of  the  thyroid  enlarge- 
ment fluctuation  may  often  be  detected;  it  may  be  localized  to  a  small 
area  of  the  lobe,  or  may  be  detected  over  the  entire  affected  lobe.  In 
some  cases,  on  palpation,  a  purring  or  thrill  is  transmitted  to  the  fingers. 
The  thrill  is  synchronous  with  the  heart's  action  and  due  to  increased 
vascularity  of  the  gland.  Auscultation  under  these  circumstances 
reveals  a  systolic  murmur. 

Causes.  Enlargement  of  the  thyroid  gland  may  be  due  to  simple 
hypertrophy,  to  fibro-cystic  enlargement,  or  to  enlargement  in  which 
the  vascularity  is  more  prominent,  as  in  exophthalmic  goitre.  In 
simple  hypertrophy  the  enlargement  is  often  intermittent,  increasing  in 
size  at  each  menstrual  period,  or  coming  on  in  pregnancy,  to  disappear 
after  labor.  It  may  then  disappear  entirely,  or  return  at  the  meno- 
pause. The  fibro-cystic  enlargement  which  occurs  in  countries  in 
endemic  form  is  persistent.  The  enlargement  which  is  chiefly  due  to 
dilatation  of  the  bloodvessels  is  usually  seen  in  exophthalmic  goitre, 
and  can  easily  be  recognized  by  the  association  of  the  remarkable  signs 
of  this  affection.     (See  Exophthalmic  Goitre.) 

Enlargement  of  the  thyroid  gland  from  the  above-mentioned  causes 
must  be  distinguished  from  enlargement  due  to  other  causes,  as 
abscess,  cancer,  sarcoma,  or  adenoma.  Abscess  usually  follows  in- 
fectious diseases;  in  the  writer's  case  it  followed  typhoid  fever.  It 
must  also  be  distinguished  from  other  tumors  in  this  region.  It  par- 
ticularly must  not  be  confounded  with  enlargement  on  the  right  side 
due  to  an  innominate  aneurism.  (See  Aneurism.)  The  distinction 
can  usually  be  made  without  difficulty.  (For  lymphatic  glands  of 
neck,  see  The  Glands.) 

The  Vessels  of  the  Neck.  Changes  take  place  in  the  arteries 
and  veins  observed  by  inspection,  palpation,  and  auscultation.  (For 
a  description  of  these  changes,  see  Arteries  and  Veins.) 

The  observation  of  the  thorax  and  abdomen  will  be  considered  under 
sections  devoted  to  affections  of  these  regions. 

The  Extremities.  The  Hands.  Color.  Observation  of  the  color 
of  the  hands  is  of  service  in  estimating  the  general  hue  and  color  of 


130  GENERAL  DIAGNOSIS. 

the  individual,  as  changes  occur  first  in  the  regions  furthest  removed 
from  the  centre  of  circulation.  (See  the  Skin — color.)  Shape. 
Changes  in  the  shape  are  pronounced  in  many  affections.  The 
spade-like  hands  of  myxoedema,  the  peculiar  shape  of  the  hands  in 
acromegalia  and  pulmonary  osteo-arthropathy,  and  their  appearance 
in  rheumatoid  arthritis  have  been  described.  In  progressive  muscular 
atrophy  (chronic  anterior  myelitis)  the  shape  of  the  hands  is  peculiar. 
The  French  name  main-en-griffe  is  applied  to  it.  There  is  loss  of 
voluntary  power  brought  about  by  the  wasting  of  the  muscles.  Both 
hands  are  affected,  although  it  may  have  begun  in  one  before  the 
other.  The  thenar  and  hypothenar  muscles  and  the  interossei  are  the 
first  to  suffer.  The  thenar  eminence  becomes  flattened,  the  base  of  the 
first  metacarpal  bone  more  prominent.  The  atrophy  of  the  abductor 
indicis  is  so  conspicuous  that  the  normal  prominence  near  the  thumb 
when  it  is  adducted  gives  place  to  a  hollow  beside  the  metacarpal  bone. 
There  are  marked  depressions  between  the  metacarpal  bones  and  the 
flexor  tendons  of  the  hands.     The  phalanges  assume  positions  that  are 


Fig.  12. 


Pseudo-muscular  atrophy.    Claw-hand.    (Gray.) 

dependent  upon  the  degree  of  atrophy  of  the  flexors  or  the  extensors 
of  the  forearm.  The  extensors  on  the  ulnar  side  usually  atrophy  the 
most,  and  the  extensors  of  the  phalanges  of  the  thumb  more  than 
that  of  its  metacarpal  bone.  A  peculiar  claw-hand  is  produced  by 
these  unequal  contractions. 

Rheumatoid  Arthritis.  The  shape  of  the  hand  somewhat  resem- 
bles that  of  muscular  atrophy.  While  there  is  considerable  atrophy 
of  the  muscles,  there  is  also  a  change  in  the  ends  of  the  bones  and  in 
the  joints.  The  ends  of  the  bones  are  enlarged  and  the  cartilages 
undergo  atrophy.  The  joints  of  the  phalanges  may  be  swollen  and 
the  tissues  infiltrated  prior  to  the  destruction  of  the  cartilage.  This 
may  have  been  going  on  for  a  long  time  with  occasional  exacerbations 
of  pain  and  tenderness.  The  enlarged  phalangeal  joints  give  to  the 
tips  of  the  fingers  a  tapering  appearance  which  is  very  characteristic. 
The  joints  gradually  become  more  immobile,  the  infiltration  disap- 
pears, and  the  enlarged  ends  of  the  bones  become  more  prominent. 
More  or  less  ankylosis  develops,  and  on  motion  the  eroded  cartilage 
gives  rise  to  crepitus  and  grating.      Osteophytes  may  form  in  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  131 

tendons,  so  that  the  joints  become  more  completely  locked.  At  times 
all  the  fingers  flex  upon  the  metacarpal  bones,  or  a  few  are  flexed 
and  others  extended.  Atrophy  of  the  muscles  is  consequent  upon  the 
disease  of  the  joint.  Sometimes  the  wasting  is  very  extreme  and 
gives  the  hand  the  appearance  that  is  seen  in  pseudo-muscular  atrophy. 
The  accompanying  general  symptoms  serve  to  distinguish  each  affec- 
tion. Rheumatoid  arthritis  is  easy  of  recognition  when  the  other 
joints  are  involved  in  the  process. 

Fig.  13. 


Rheumatoid  arthritis.  The  tapering  fingers  are  seen.  The  phalangeal  joints  are  swollen ;  many- 
are  ankylosed.  The  wrist  is  stiff.  The  muscles  are  atrophied ;  the  forearm-muscles  much 
wasted. 

Deformities  of  the  hand  from  other  causes  than  the  ones  just 
mentioned  are  often  observed.  Temporary  contractures  occur  in  tet- 
any, in  temporary  hemiplegia  or  monoplegia,  and  in  paralysis  of  the 
extensors.  Then  we  have  paralysis  of  the  median,  ulnar,  and  other 
nerves,  with  their  characteristic  deformity.  (See  Nervous  Diseases.) 
So-called  wrist-drop  is  seen  in  peripheral  neuritis  (musculo-spiral 
nerve),  particularly  in  the  form  due  to  lead.  When  unilateral  it  is 
due  to  paralysis  of  the  musculo-spiral  nerve.  The  hand  hangs  from  the 
wrist  on  account  of  paralysis  of  the  extensor  muscles.  Both  hands  may 
drop,  although  it  sometimes  happens  that  one  is  affected  from  a  few  days 
to  a  few  weeks  before  the  other.  It  develops  gradually.  At  first  the 
patient  cannot  extend  the  fingers  at  the  metacarpo-phalangeal  joints. 
The  thumb  also  suffers,  and  the  weakness  of  the  extensors  is  most 
marked  on  the  ulnar  side.  In  the  beginning,  if  the  first  phalanges 
are  passively  straightened,  the  distal  phalanges  can  be  extended  by  the 
unaffected  interossei  muscles.  The  loss. of  power  extends  to  the  wrist. 
The  extensors  of  the  wrist  do  not  suffer  equally.  Those  of  the  radial 
side  are  affected  first.     When  the  paralysis  is  complete  the  hand  drops 


132 


GENERAL  DIAGNOSIS. 


and  cannot  be  brought  to  the  level  of  the  forearm.  It  may  be  noted 
that  if  the  fingers  are  flexed  passively,  the  patient  is  able  to  close  the 
fist  as  long  as  the  special  extensors  of  the  wrist  retain  power.  If, 
however,  the  fingers  are  extended,  the  wrist  cannot  be  extended.  The 
muscles  affected,  therefore,  are  the  common  extensor  of  the  fingers,  the 
extensor  indicis,  the  extensor  of  the  phalanges  of  the  thumb,  and  those 
of  the  wrist.  The  flexors  of  the  fingers  are  unaffected.  The  continued 
over-flexion  of  the  carpus  produces  slight  displacement  backward  of 
the  carpal  bones,  and  a  prominence  forms  over  the  carpus  and  the  dor- 
sunTof  the  hand.      It  is  known  as  Gubler's  tumor. 


Fig.  14. 


Photograph  of  a  case  of  lead-paralysis  affecting  the  extensor  muscles.    (Gray.) 


The  Skin.  The  skin  of  the  hand  need  not  be  considered  apart  from 
the  skin  of  the  rest  of  the  body.  It  is  smooth  or  rough,  dry  and  harsh, 
moist  and  warm,  under  the  same  circumstances  that  affect  the  skin 
generally.  In  rheumatoid  arthritis  it  has  been  described  as  peculiar. 
Both  the  dorsal  surface  and  the  palm  are  moist  and  very  soft,  and  the 
former  is  dotted  with  freckles. 

The  swellings  of  the  hand,  inflammatory  or  cedematous,  do  not  differ 
from  swellings  in  other  portions  of  the  body,  whether  the  joints  or  the 
subcutaneous  connective  tissue  are  affected,  except  in  the  cases  pre- 
viously mentioned.     (See  Skin.) 

Fingers.  In  gout  and  rheumatism  the  fingers  present  changes.  The 
swellings  of  the  joints  belonging  to  each  condition  cannot  well  be  dis- 
tinguished. In  gout,  tophi  are  likely  to  be  present  in  the  joints  or 
along  the  tendons,  on  account  of  great  accumulation  of  urate  of  soda. 
They  are  more  prominent  on  the  dorsal  surface  of  the  joints,  and  some- 
times break  through  the  skin,  so  that  the  ' '  chalk-like  ' '  concretion 


THE  DATA   OBTAINED  BY  OBSERVATION.  133 

exudes.    It  was  said  by  Sir  Thomas  Watson  that  a  gouty  subject  under 
his  care  used  his  joints  to  keep  tally  while  playing  cards. 

Heberden's  Nodes.  Haygarth's  nodosities.  The  term  "  end- 
joint  arthritis ' '  is  also  applied  to  this  condition.  This  node  belongs 
to  the  first  of  the  three  divisions  Charcot  makes  of  rheumatoid  arth- 
ritis. The  nodules  develop  gradually  at  the  sides  of  the  distal  pha- 
langes. The  subject  may  be  in  good  health,  or  may  have  had  attacks 
of  gout,  or  have  suffered  from  acid  dyspepsia.  At  first  the  joints 
may  be  a  little  swollen  and  tender.  The  swelling  and  tenderness  may 
be  periodical,  and  the  size  may  be  increased  with  each  fresh  parox- 
ysm. The  tubercles  are  seen  at  the  side  of  the  dorsal  surface  of  the 
second  phalanx,  the  corresponding  cartilage  becomes  soft,  the  ends  of 
the  bone  may  be  eburnated.  A  moderate  anchylosis  takes  place.  The 
nodules  are  often  considered  of  good  prognostic  omen;  it  is  even  said 
that  they  are  a  sign  of  longevity.  It  is  certain  that  the  large  joints 
are  rarely  involved  when  these  nodules  are  present. 

The  fingers  in  acromegalia,  myxoedenia,  and  pulmonary  osteo-arthro- 
pathy  have  been  described.  The  tips  of  the  fingers  may  be  bulbous,  or 
club-shaped,  in  some  cases  of  phthisis  and  of  other  forms  of  chronic  lung 
disease  and  also  of  chronic  heart  disease.  It  is  most  common,  how- 
ever, in  bronchitis  and  phthisis.  The  clubbing  is  associated  with 
changes  in  the  nails  (see  below).  In  addition  to  the  nodosities  above 
mentioned,  extra-articular  tophi  developing  in  the  course  of  gout  must 
be  mentioned. 

Deviations  in  the  Position  and  Shape  of  the  Fingers. 
The  changes  in  the  shape  of  the  fingers  have  been  described  in  connec- 
tion with  the  changes  in  the  shape  of  the  hands.  Eversion  is  charac- 
teristic of  rheumatoid  arthritis,  but  deviations  due  to  abnormal  flexion 
or  extension  produce  the  most  marked  changes.  Flexion  of  the  first 
phalanx  of  the  little  finger  is  due  to  contraction  of  the  palmar  fascia, 
or  to  paralysis  of  the  common  extensor  from  disease  of  the  musculo- 
spiral  nerve. 

Contraction  of  the  fascia  of  the  hand,  causing  more  or  less  flexion 
of  the  little  and  ring  fingers,  is  frequently  seen  and  may  be  an  indica- 
tion of  gouty  diathesis.  It  is  certain  that  these  contractions  are  seen 
in  several  members  or  generations  of  a  family  in  which  gout  is  preva- 
lent.    It  is  called  Dupuytren's  contraction. 

Abnormal  extension  is  usually  very  marked.  Hyper-extension  of 
the  middle  phalanx  is  due  to  paralysis  of  the  flexor  sublimis  from  dis- 
ease of  the  median  nerve;  byper-ex tension  of  the  distal  phalanges  to 
paralysis  of  the  flexor  profundus  muscle  from  disease  of  the  median 
and  ulnar  nerves.  In  main-en- cjr  iff e,  previously  described,  there  is 
extension  of  the  proximal  phalanx,  with  extreme  flexion  of  the  two 
distal  phalanges,  due  to  contraction  of  the  long  extensor  and  of  the 
flexors.  Contractions  due  to  chorea  or  to  central  lesions,  as  post-hem  i- 
plegic  contractions,  will  be  considered  under  special  diagnosis.  It  is 
thus  seen  that  the  peculiar  combined  extension  and  flexion,  causing 
abnormal  shape  of  hands  and  fingers,  is  due  to  (1)  local  joint  inflam- 
mation (subluxations);  (2)  local  neuritis  and  paralysis;  (3)  progressive 
(spinal)  muscular  atrophy;  (4)  idiopathic  muscular  atrophy,  rarely. 


134 


GENERAL  DIAGNOSIS. 


Athetosis  is  a  peculiar  spasmodic  affection  of  the  fingers  and  toes,  often 
hereditary,  and  nearly  always  associated  with  imbecility  or  some  intra- 
cranial lesion.  It  may  be  unilateral  or  bilateral.  There  is  contraction 
or  paralysis  of  the  affected  limb.  The  muscles  may  be  atrophied  or 
hypertrophied.  It  is  characterized  by  slow,  wavy,  and  gradual  move- 
ments, which  are  incessant.  The  fingers  constantly  tend  to  pronate, 
but  the  toes  do  not  separate. 


Fig.  15. 


Case  of  athetosis.    (Gray.) 


Tropho-neurosis  of  Fingers.  We  observe  changes  in  the  nutri- 
tion and  circulation  of  the  fingers  in  many  nerve-affections. 

The  Circulation.  Raynaud's  Disease.  Local  asphyxia.  In  cer- 
tain vasomotor  affections  the  hand  or  fingers  become  pale  and  intensely 
cold  ;  they  are  the  seat  of  numbness,  and  are  without  sensation.  The 
term  "  dead  fingers  "  graphically  describes  the  appearance.  The  pallor 
usually  comes  on  suddenly,  and  continues  for  a  shorter  or  longer  period. 
In  some  instances  it  occurs  in  distinct  paroxysms.  As  the  pallor  dis- 
appears, there  is  a  gradual  return  of  warmth  and  the  color  changes  to 
a  livid  red,  dark  blue,  or  even  blackish  hue.  In  some  cases  the  lividity 
becomes  so  intense  that  gangrene  ensues  in  small  superficial  spots,  or 
even  involves  the  whole  finger.  Pain  may  or  may  not  be  present, 
and  does  not  increase  when  the  hand  hangs  down.  The  tip  of  the 
nose  and  the  lobe  of  the  ear  may  be  affected,  and  occasionally  other 
parts  of  the  surface.  The  sensitiveness  to  touch  is  markedly  lessened. 
Raynaud's  disease  occurs  usually  in  ill-nourished  subjects,  or  after  an 
acute  disease,  as  typhoid  fever.  It  may  be  associated  with  vascular 
spasm  in  internal   organs,   giving  rise   to   epilepsy,  hemoglobinuria, 


THE  DATA  OBTAINED  BY  OBSERVATION.  135 

temporary   aphasia,    or   hemiplegia.       It  ■  is   usually   worse   in   cold 
weather. 

Erythromelalgia.  Local  changes  in  color  are  often  due  to  neu- 
ritis either  of  the  trunk  or  of  the  terminal  endings  of  the  nerves. 
When  such  changes  are  associated  with  pain  we  use  the  term  erythro- 
melaloia.  It  is  characterized  bv  redness  of  the  surface  with  increased 
temperature;  it  is  usually  seen  in  the  extremities  and  is  limited  to  the 
distribution  of  the  affected  nerve.  It  is  worse  in  summer,  increased 
by  artificial  heat,  and  aggravated  when  the  extremity  is  dependent  or 
pressed  upon.  The  redness  is  attended  by  burning  and  extreme  local 
discomfort,  in  which  all  sorts  of  sensations  are  described  :  tearing  of 
the  finger-nails,  pulling  or  pricking  of  the  skin,  twistings  of  thousands 
of  needles,  and  other  forms  of  torture.  I  know  of  no  peripheral  pain 
which  is  the  source  of  greater  agony. 

Glossy  Skin  is  seen  after  nerve-injuries  and  neuritis,  and  in  cen- 
tral affections  in  which  the  trophic  nerves  are  involved.  The  skin 
is  shiny,  smooth,  drawn  very  tightly  over  the  surface,  and  sometimes 
atrophied.  Red  and  pale  mottling  may  be  seen.  The  surface  is  free 
from  hair.  Burning  pain  precedes  and  accompanies  the  change.  (See 
Kails.) 

Other  pronounced  trophic  changes  are  seen  in  the  extremities.  Per- 
forating ulcer  of  the  foot  is  an  example;  it  is  usually  seen  in  affections 
of  the  general  nervous  system,  such  as  tabes  dorsalis. 

The  Nails.  The  Shape.  The  appearance  of  the  nails  enables  us 
to  estimate  the  duration  of  certain  diseases,  or  the  time  when  convales- 
cence began;  it  also  indicates  local  interference  with  the  nutrition  of 
the  parts.  Thus,  curving  of  the  nails,  with  the  club-shape  of  the 
finger-ends,  occurs  only  in  chronic  diseases,  as  phthisis  or  emphysema, 
or  in  chronic  cardiac  disease  and  aneurism.  In  the  latter  it  is  some- 
times found  on  one  hand  only.  It  is  sometimes  seen  in  other  chronic 
wasting  diseases.  The  nails  may  curve  transversely  or  longitudinally. 
When  trausversely  the  appearance  is  like  that  of  a  filbert,  and  when 
longitudinally  they  are  said  to  be  incurvated.  This  change  in  shape 
may  occur  without  clubbing  of  the  fingers.  The  shape  is  altered  in 
acromegalia  and  pulmonary  osteo-arthropathy  (see  pp.  66,  67). 

Color.  AVhite  marks  on  the  surface  are  usually  seen  after  an  ill- 
ness, and  may  indicate  the  date  of  recovery.  The  marks  develop  at 
the  root  of  the  nail,  and  as  the  nail  grows  the  marks  approach  the  tips 
of  the  fingers,  and  thus  their  position  denotes  the  time  that  has  elapsed 
since  convalescence  set  in  If  they  are  seen  half-way  up  the  nails, 
convalescence  is  probably  of  three  months'  standing.  We  get  a  good 
idea  of  the  condition  of  the  blood  in  the  capillaries  from  the  appearance 
of  the  tissue  under  the  nails.  If  there  is  ansemia,  pressure  on  the 
finger-tips  will  drive  the  blood  from  the  capillaries.  Stephen  Mac- 
kenzie's rule,  that  if  such  pressure  completely  empties  the  vessels  so 
that  they  become  pale,  it  indicates  that  the  globular  richness  of  the 
blood  is  reduced  one-half,  is  a  fair  and  rapid  test  of  the  degree  of  the 
anamiia.  The  purplish  and  bluish-black  discoloration  of  cyanosis 
previously  referred  to  is  first  seen  under  the  nails.     Sometimes  the 


136 


GENERAL  DIAGNOSIS. 


capillaries  pulsate,  and  this  •  pulsation  is  more  visible  under  the  nails 
than  in  any  other  parts  of  the  body,  except  the  retina.  It  may  occur 
in  the  aortic  regurgitation. 


Fig.  16. 


Clubbed  fingers  with  curved  nails  (middle  finger  slightly  flexed). 

Nutritive  Changes.  The  nails  undergo  chronic  inflammation 
with  destruction  in  various  skin  affections,  and  the  matrix  is  the  seat 
of  acute  inflammation  in  onychia.  Onychia  may  be  simple  or  syphil- 
itic. Its  presence  may  indicate  the  organic  origin  of  otherwise  obscure 
nervous  symptoms.  It  may  be  only  a  simple  inflammation,  or  it  may 
result  in  the  loss  of  the  nail  and  necrosis  of  the  bone. 

Deformity  of  the  nails  (toe)  occurs  in  acute  and  chronic  myelitis.  In 
locomotor  ataxia  the  nails  fall  out. 

In  neuritis  the  trophic  change  is  marked;  the  growth  is  arrested,  and 
the  nail  becomes  dark  and  brittle  and  curved  in  its  long  axis,  while 
lateral  arching  takes  place.  The  cutis  underneath  thickens,  and  the 
skin  at  the  base  retracts.  The  fingers  may  be  clubbed.  TThen  growth 
is  resumed  a  distinct  roughened  line  of  demarcation  is  seen.  In  lep- 
rous neuritis  there  is  destruction  of  nails  and  phalanges.  In  some 
cases  the  nails  become  dry,  scaly  and  cracked,  or  atrophy  entirely.  In 
the  hemiplegia  from  cerebral  apoplexy  the  growth  is  arrested  on  the 
paralyzed  side.  This  is  tested  by  staining  the  nails  of  the  two  hands 
at  the  same  level  with  nitric  acid;  the  relative  position  of  the  stain 
upon  corresponding  nails  of  the  two  hands  will  show  whether  there 
has  been  growth  or  not.  The  return  of  functional  power  is  indicated 
by  renewed  growth. 

The  Feet.  The  feet  and  ankles  are  examined  to  determine  the  color, 
the  temperature,  the  occurrence  of  swelling  (oedema),  and  fixation. 
Pain  in  the  feet  has  been  referred  to;  oedema  has  also  been  discussed. 
The  changes  in  color  are  allied  to  similar  changes  in  the  hand,  if  bilat- 
eral. 

Cold  Hands  and  Feel.     Patients  frequently  complain  of  changes  in 


THE  DATA  OBTAINED  BY  OBSERVATION.  137 

the  temperature  of  the  extremities,  and  on  examination  Ave  find  it  act- 
ually reduced.  It  is  a  common,  and  often  serious,  complaint.  It  is 
natural  to  expect  a  peripheral  coldness  when  the  central  organ  of  circu- 
lation is  weakened.  Coldness  takes  place  in  the  final  hours  preceding- 
death.  It  occurs  in  collapse,  in  hemorrhage,  and  in  shock.  But  we 
also  see  it  in  organic  disease  of  the  heart,  with  impairment  of  the  circu- 
lation. It  is  a  common  vasomotor  condition  in  nervousness,  indepen- 
dently of  hysteria.  It  is  a  marked  feature  in  Nothnagel's  angina 
pectoris  vaso  motoria,  as  well  as  in  true  and  false  angina  pectoris.  A 
visit  to  a  physician,  excitement  from  any  cause,  is  likely  to  be  attended 
by  coldness  of  the  hands  and  feet.  Under  these  circumstances  the 
extremities  are  often  bathed  in  a  cold  and  clammy  perspiration.  In 
senile  endarteritis  cold  hands  and  feet  frequently  occur.  They  are  an 
index  to  the  state  of  the  peripheral  circulation  in  other  parts  of  the 
body,  as  the  brain. 

The  poisons  of  gout  aud  rheumatism  and  other  diseases,  which  irri- 
tate peripheral  and  vasomotor  nerves,  may  cause  cold  hands  and  feet. 
In  gastric  and  intestinal  dyspepsia,  with  the  absorption  of  toxic  prin- 
ciples, as  leucoma'ines,  this  symptom  may  be  present. 

Changes  of  sensation  in  the  skin  of  the  extremities  will  not  be  con- 
sidered in  this  section.  They  will  be  taken  up  in  the  chapters  devoted 
to  the  diseases  of  the  nerve-.  It  is  sufficient  to  state  that  anesthesia 
in  local  areas  and  due  to  causes  limited  to  the  skin  is  seen  in  morphcea, 
in  the  anaesthetic  form  of  leprosy,  and  in  certain  ischemic  states  (urti- 
caria). It  is  accompanied  by  loss  of  tactile  sensibility.  Hyperesthesia 
aud  paresthesia  occur  with  various  local  affections,  but  they  are  without 
diagnostic  significance,  except  in  nervous  diseases. 

The  Lymphatic  Glands.  (See  Neck.)  Information  of  diagnostic 
value  may  be  obtained  from  the  condition  of  the  lymphatic  glands. 
Enlargement  may  be  general  or  local. 

Enlargement  of  the  post-cervical  glands,  the  epitrochlear  glands,  and 
lymphatic  glands  in  other  portions  of  the  body,  points  to  syphilis.  In 
the  two  first-mentioned  localities  the  enlargement  is  of  great  diagnostic 
importance,  as  it  is  less  likely  to  be  due  to  any  other  causes.  Suppu- 
rating glands  do  not  here  concern  us.  Inguinal  and  axillary  enlarge- 
ment. With  or  without  suppuration,  enlargement  always  points  to  an 
irritation  or  lymphatic  invasion  in  the  area  drained  by  the  affected 
lymphatic  gland.  When  in  the  groins  the  feet  are  affected,  and  when 
in  the  axillae  the  hands.  Great  enlargement  in  either  situation  causes 
oedema  of  the  corresponding  extremity,  if  the  veins  are  pressed  upon. 
The  axillary  glands  are  early  affected  and  enlarged  in  mammary  cancel'. 
The  breast  should  always  be  examined  in  oedema  of  the  arm. 

The  supra-clavicular  glands.  These  glands  are  often  enlarged  and 
indurated,  and  may  cause  pressure  symptoms.  The  only  local  enlarge- 
ment that  is  of  special  diagnostic  significance  is  that  which  is  seen 
above  the  clavicle  on  the  left  side.  They  often  point  to  carcinoma  of 
the  stomach.  Indeed  there  are  cases  of  this  disease  in  which  only  the 
general  symptoms  of  carcinoma  are  present.  Local  symptoms  are 
wanting,   and  the  locality  of   the  cancer  cannot  be  made  out.      The 


138  GENERAL  DIAGNOSIS. 

■ 

enlarged  glands  above  the  clavicle  are  a  pretty  sure  indication  that  the 
stomach  is  the  seat  of  the  disease.  The  enlargement  is  probably  due 
to  transmission  of  the  infection  along  the  thoracic  duct  and  its  lodgment 
in  the  associated  glands. 

The  cervical  and  sub-maxillary  glands.  Enlargement  of  the  sub-max- 
illary and  cervical  glands  points  to  affections  of  the  mouth  and  throat, 
or  of  the  jaw  and  teeth.  It  is  caused  particularly  by  infectious  disor- 
ders in  these  localities.  They  are  often  the  seat  of  nodular  enlargement 
in  actinomycosis.      (See  "collar"  in  adenitis  of  leuksernia.) 

The  glands  are  enlarged  in  simple  adenitis,  in  tuberculosis,  Hodg- 
kin's  disease,  leucocythccmia,  sarcoma,  and  cancer.  The  moderate 
enlargement  of  syphilis  and  the  local  enlargement  from  irritation  in  the 
area  of  lymph-drainage  have  been  mentioned.  Adenitis  is  usually 
local.  The  gland  is  tender;  the  connective  tissue  around  it  is  affected. 
There  are  local  heat  and  pain.  At  first  the  gland  is  hard,  later  it 
softens  in  the  centre,  and  finally  it  exhibits  fluctuation.  In  tuberculosis 
more  than  one  gland  is  affected.  Usually  the  glandular  involvement 
is  bilateral  (as  in  the  neck).  At  first  the  glands  are  isolated.  Later 
they  become  matted.  The  local  symptoms  are  not  marked,  and  the 
process  is  very  indolent.  Thick,  cheesy  pus  is  discharged  which  may 
contain  tubercle  bacilli.  The  pus  always  causes  tuberculosis  when 
inoculated  in  lower  animals.  Fever  and  "decline"  occur  later,  but 
often  not  until  other  structures,  as  the  lungs,  are  infected.  (See 
Hodgkin's  Disease,  and  Leucocytheemia.) 

Scars  at  the  site  of  former  glands  point  to  tuberculous  destruction 
or  former  bubo,  and  are  suggestive. 

Lymphangitis  or  angioleucitis.  The  streaked  redness  over  the  surface 
of  the  skin,  with  tenderness  along  the  course  of  the  lymphatics  and 
cedenia,  is  characteristic  of  inflammation  of  the  lymphatic  vessels,  and 
need  not  be  further  mentioned.  The  glandular  and  dermal  changes  of 
elephantiasis,  with  chyluria,  with  or  without  lymph  scrotum,  are  unmis- 
takable; the  disease  is  due  to  the  filar ia  sanguinis  hominis. 

Muscles.  The  Nutrition.  The  nutrition  of  the  muscles  is  observed 
by  the  hand  of  the  examiner  while  the  muscles  are  made  to  relax  and 
contract  alternately.  We  compare  corresponding  muscles  of  the  two 
sides.  Measurement  of  the  limbs  at  corresponding  situations  makes 
the  observation  more  accurate.  The  muscles  may  atrophy  or  hyper- 
trophy. Either  condition  may  be  local,  unilateral,  or  general  and 
bilateral. 

Atrophy.  There  are  several  varieties  of  atrophy :  1.  The  atrophy 
of  disuse.  2.  The  atrophy  of  degeneration  or  myelopathic  jatrophy. 
It  follows  lesions  of  the  motor  path,  of  the  cortex,  medulla  or  spinal 
cord,  and  neuritis.     (See  Nervous  Diseases.)     3.   Myopathic  atrophy. 

Atrophy  from  disuse  and  from  disease  of  the  muscles  must  be  dis- 
tinguished from  atrophy  due  to  disease  of  the  nerves  (neuritis)  and  to 
degeneration  of  motor  nerves  and  ganglia.  Disuse.  It  is  also  known 
as  the  atrophy  of  inactivity.  The  muscles  are  slightly  diminished  in 
volume.  The  atrophy  takes  place  very  slowly;  it  supervenes  in 
cases  of  paralysis,    and    in    joint-disease  which   causes  immobility  of 


THE  DATA  OBTAINED  BY  OBSERVATION.  139 

the  limb.  It  occurs  also  in  joint-disease  from  reflex  influences.  The 
electrical  reactions  of  the  muscles  are  qualitative  and  unchanged. 

Myopathic  Atrophy.  In  this  form  of  atrophy  the  muscle  is 
diseased.  It  diminishes  in  volume,  and  finally  becomes  completely 
shrunken.  Complete  paralysis  rarely  ensues,  but  the  reaction  of 
degeneration  cannot  be  determined. 

Idiopathic  Muscular  Atrophy.  In  this  affection  muscular  wasting 
takes  place  with  or  without  initial  hypertrophy.     Three  forms  are  seen  : 

1.  Atrophy,  with  Pseudo-hypertrophy.  .  It  usually  begins  in  child- 
hood, and  is  often  of  congenital  origin,  being  transmitted  through 
the  mother.  It  is  first  noticed  just  as  the  child  is  learning  to  walk. 
The  extensors  of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoids, 
and  the  triceps  and  infraspinati  muscles  are  involved,  but  the  first 
change  takes  place  in  the  muscles  of  the  calves.  The  muscles  of  the 
face,  neck,  and  forearm  are  not  usually  affected  in  this  form  of  the  dis- 
ease; the  muscles  of  the  hand  are  not  involved.  While  hypertrophy 
progresses  in  certain  muscles,  others  waste.  The  calves  may  hyper- 
trophy, for  instance,  while  the  extensors  of  the  leg  waste  away  and 
become  weak.  Attitude  and  gait  are  characteristic  (see  page  61).  The 
patient  stands  erect,  with  the  legs  apart,  the  shoulders  thrown  back, 
the  spine  curved,  and  the  abdomen  prominent.  The  waddling  gait  is 
characteristic,  and  the  method  of  getting  up  from  the  floor  is  pathogno- 
monic. The  course  of  the  disease  is  slow,  wasting  follows  the  hyper- 
trophy, but  the  weakness  is  greatest  in  the  muscles  first  atrophied. 
Contractures  and  distortions  of  the  spine  and  of  the  bones  of  the  leg 
take  place. 

2.  Primary  Atrophy.  This  is  likewise  congenital,  or  manifests 
itself  in  early  life.  It  is  divided  into  different  types  according  to  the 
groups  of  muscles  that  are  affected.  The  same  process  occurs  as  in  the 
former,  except  that  pseudo-hypertrophy  is  not  primary.  There  may 
be  several  forms  in  different  members  of  the  same  family. 

The  Juvenile  Form  qfJErb.  The  upper  arm  and  shoulder  and  the  thigh 
muscles  are  first  involved.  Later  the  muscles  of  the  gluteal  region 
and  calf  may  become  enlarged  and  hard.  The  back  muscles  are 
gradually  affected,  inducing  the  attitude  previously  mentioned.  The 
reaction  of  degeneration  is  not  present.  In  addition,  the  infantile 
type  first  described  by  Duchenne,  or  the  fascio-scapulo-humeral  type 
is  seen.  Erb's  form  begins  about  puberty.  The  other  forms  usually 
begin  in  childhood,  but  may  be  delayed.  The  face  is  involved;  it 
is  expressionless,  and  in  laughing  the  muscles  move  slowly;  the  child 
cannot  whistle,  as  the  lips  are  thick  and  everted.  The  eyes  remain 
partly  open.  The  muscles  of  the  group  waste;  later,  the  thighs  be- 
come involved.  Erb  has  given  a  useful  test  to  determine  the  strength 
of  the  shoulder  and  girdle  muscles.  When  the  child  is  lilted  by  the 
armpits,  if  the  scapulo-hutneral  groups  are  weak,  the  shoulders  are 
forced  up  to  the  child's  ears  without  resistance. 

3.  Peroneal  Atrophy.  A  peroneal  type  of  muscular  atrophy  has 
been  described  by  Charcot.  The  extensors  of  the  great  toe  and 
afterward  the  common  extensors  and  peronei  muscles  arc  affected; 
club-foot  results.   The  muscles  of  the  tlvgh  may  become  involved  Intel-. 


140  GENERAL  DIAGNOSIS. 

When  the  disease  occurs  in  childhood  it  gradually  spreads  to  the  upper 
extremities  and  affects  the  muscles  of  the  hand,  differing  in  this  respect 
from  other  forms  of  muscular  atrophy.  The  thenar,  hypothenar,  and 
interossei  muscles  are  symmetrically  involved,  producing  the  claw-hand. 
Unlike  the  other  forms  of  atrophy  embraced  under  this  heading,  the 
peroneal  type  is  attended  by  disturbances  of  sensation,  and  by  pain, 
fibrillary  contractions,  and  vasomotor  changes.  The  reactions  of  degen- 
eration may  be  present.  It  is  thought  by  competent  observers  to  be 
simply  a  form  of  neuritis ;  and  it  is  also  called  progressive  neural 
muscular  atrophy. 

Diagnostic  Features  of  Myopathic  Atrophies.  The  disease  is  charac- 
terized by  gradual  progression  of  the  wasting  and  weakness  in  various 
groups  of  muscles  not  specially  related.  "We  never  see  wasting  of 
the  intrinsic  muscles  of  the  hand^,  as  in  the  spinal  forms  of  muscular 
atrophy,  or  of  the  tongue,  pharynx,  larynx,  and  eye.  Eectrical  irrita- 
bility is  lessened,  and  reaction  of  degeneration  is  not  present.  Fibril- 
lary twitching  is  not  seen.  Sensation  is  not  affected.  The  reflexes 
are  diminished,  and  later  may  be  lost.  The  sphincters  are  not 
involved;  deformities  about  the  joints  or  in  the  spinal  column  may  occur. 

The  diagnosis  of  idiopathic  muscular  atrophy  is  not  difficult,  if  the 
above-mentioned  facts  are  boine  in  mind.  The  fact  that  it  occurs  in 
family  groups  is  an  important  point  in  the  diagnosis.  In  cerebral 
atrophy  there  is  primary  loss  of  power.  In  chronic  anterior  poliomyelitis 
{spinal  atrophy)  atrophy  begins  in  the  muscles  of  the  hands;  in  both 
the  simple  and  spastic  form  there  are  reactions  of  degeneration,  fibril- 
lary twitching,  and  increase  in  the  reflexes,  and,  in  the  latter,  spastic 
contraction  of  the  legs.  The  myopathies  occur  early  in  life  and  are 
hereditary. 

In  neuritis  the  paralysis  is  proportionately  greater  than  the  atrophy. 
Sensory  symptoms  are  often  present.  The  cause  is  distinct.  There  is 
no  family  history. 

General.  Atrophy.  In  cachexias  the  muscles  as  well  as  the 
tissues  undergo  atrophy.  Even  in  nervous  diseases  the  atrophy  of  the 
muscles  markedly  increases  when  general  wasting  takes  place. 

Raymond's  Table  of  Atrophies. 

r  Atrophy  from  compression. 
Circumscribed  atrophies   .    .  <  Atrophy  in  inflammatory  conditions  (pleurisy,  joint-disease,  etc.). 
I  Atrophy  from  injury  or  inflammation  of  individual  nerves. 

f  Progressive  spinal  muscular  atrophy ;  type  Aran  Duchenne. 

r  Pseudo-hypertrophic  muscular  paralysis. 
I  Type  Leyden-Mubius. 
Progressive  atrophies    .    .    .  ■{   Progressive  my0pathicJ  T™e  Zimmerlin. 

atrophy 1  Type  Erb. 

|  Type  Landouzy-Dejerine. 
I.  L  Type  Charcot-Marie. 

f  f  Infantile  form. 

|  Acute  of  adults  :  spinal  paralysis,  with 
rapid  course  and  curable  (Landouzy- 
Diffuse  atrophies j  Anterior  poliomyelitis  j      Dejfirine) ;  subacute  and  chronic  form  ; 


■! 


I  Syringomyelia. 


chronic  mixed  form  (Erb);  diffuse 
subacute,  general  6pinal  paralysis 
(Ducheunt ). 


THE  DATA   OBTAINED  BY  OBSERVATION.  141 

(  (-Lead  paralysis. 

Facial  hemiatrophy  .    .    .    .  J  Multiple  neuritis  J  Leprous  neuritis 

I     (amyotrophic  form)     ( Alcoholic  neuritis. 

Muscular  atrophies  of  cere-  f  With  secondary  degeneration  involving  the  anterior  cornua. 
bral  origin \  Without  secondary  degeneration  involving  the  anterior  cornua. 

Muscular  atrophy  in  hvsteria  -\    ,  ..       , 

,         .       /     .  Amyotrophic  sclerosis. 

Muscular  atrophy  from  sys-  >  _.         ,  f\    ,  .  .     . 

•    j,-  ,\.  -,  Glosso-labio-larvngeal  paralvsis. 

temic  disease  of  the  cord    .  ' 

f  Atrophy  in  myelitis. 

Atrophy  complicating  other  !  Atrophy  in  compression  of  the  cord. 

disease  of  the  cord     ...   I  Atrophy  in  multiple  sclerosis. 

L  Atrophy  in  tabes  dorsalis. 

Hypertrophy.  Hypertrophy  of  individual  muscles  occurs  from 
overuse,  and  is  seen  when  one  extremity  or  portion  of  the  trunk  is 
used  in  excess.  General  hypertrophy  of  muscles  occurs  in  Thomsen's 
disease.  True  hypertrophy  is  recognized  by  increased  volume,  great 
hardness,  aud  increased  vigor  of  the  muscle. 

Pseudo-hypertrophy  (see  under  Muscular  Atrophy)  is  associated  with 
increased  volume  of  muscle,  but  diminished  power. 

Thomsen's  Disease  (Myotonia  congenita).  This  is  an  hereditary  dis- 
ease and  may  occur  in  several  generations  of  a  family.  Tonic  cramps 
take  place  in  the  muscles  when  voluntary  movements  are  attempted. 
The  disease  begins  in  childhood,  rarely  after  puberty.  The  muscles 
become  rigid  and  fixed  when  put  in  action.  The  lack  of  voluntary 
control  of  the  muscles  is  shown  by  the  slow  contraction  and  relaxa- 
tion when  voluntary  efforts  are  made.  The  rigidity  may  w^ear  off 
and  the  limb  can  then  be  used.  It  is  particularly  noticeable  when 
walking  is  attempted;  as  the  leg  is  advanced  slowly  it  may  remain  stiff 
for  a  second  or  two,  but  alter  it  becomes  limber  the  patient  can  walk 
for  hours.  If  he  stops  wTalking,  the  same  difficulty  is  experienced  when 
he  starts  aaaim  Both  arms  and  legs  are  affected.  Patients  are  usually 
well  nourished,  however.  There  are  no  atrophies.  The  muscles  are 
irritable,  so  that  mechanical  stimulus  or  pressure  causes  tonic  contrac- 
tion. Movement  and  cold  aggravate  it.  Sensation  and  the  reflexes 
are  not  affected,  and  there  is  no  evidence  of  disease  of  the  cerebro-spinal 
system,  save  the  occurrence  of  hypochondriasis  in  some  cases.  The 
myotonic  reaction  described  by  Erb  is  induced.  (See  electrical  diag- 
nosis— Diseases  of  the  Xerves.) 

Paramyoclonus  Multiplex.  In  this  affection  there  is  clonic  contrac- 
tion of  the  muscles.  It  is  usually  confined  to  the  extremities,  and 
occurs  in  paroxysms.  It  may  have  been  caused  by  sudden  twitching 
or  violent  motion.  The  clonic  spasms  at  first  do  not  interfere  with  the 
patient' s  occupation,  but  gradually  they  increase.  Both  legs  are  affected 
and  the  number  of  contractions  varies  from  50  to  150  a  minute.  The 
contractions  may  be  rhythmical.  In  severe  cases  the  muscles  of  the 
back  and  abdomen  contract  violently.  Tremors  of  the  muscles  may 
be  present  in  the  intervals.  (  For  spasm,  tremor,  contraction,  etc.  see 
Nervous  Diseases.) 

Myositis.  Inflammation  of  the  muscles:  (See  also  Trichinosis. )  In 
inflammation  of  the  muscles  there  are  pain,  swelling,  and  loss  of  power. 


142  GENERAL  DIAGNOSIS. 

In  universal  myositis  the  inflammations  begin  in  the  lower  extremities 
and  gradually  involve  other  muscles  of  the  body.  They  are  swollen, 
hard,  and  painful  on  pressure.  Atrophy  supervenes  in  groups  of  mus- 
cles. The  muscles  may  become  more  or  less  rigid.  Local  oedema  of 
the  skin  over  the  muscles  occurs.  The  progress  is  gradual,  and  death 
ensues  when  the  respiratory  muscles  are  involved. 

The  three  cardinal  symptoms  that  attend  the  disease  as  described  by 
Loenfeld  are  :  (1)  Swelling  of  the  extremities  due  to  subcutaneous 
oedema  and  swelling  of  the  muscle,  causing  functional  disturbance; 
(2)  extension  to  the  muscles  of  respiration  and  deglutition;  (3)  a  more 
or  less  extensive  eruption.  The  latter  is  erythematous,  its  distribution 
is  usually  general  but  irregular,  and  may  be  followed  by  pigmentation. 
The  disease  must  not  be  confounded  with  trichinosis.  In  the  latter, 
examination  of  a  small  portion  of  muscle  reveals  the  trichinae. 

Progressive  ossification  of  the  muscles  is  rare.  The  muscle-tissues 
undergo  gradual  ossification,  either  in  localized  spots  or  in  widespread 
areas.  Inflammation  of  the  muscle  precedes  the  ossification.  As  the 
inflammatory  swelling  subsides,  the  muscles  become  hard  and  are  grad- 
ually converted  into  bony  tissue.     The  disease  lasts  many  years. 

The  Bones.  The  examination  is  made  by  inspection  and  palpation. 
The  bones  are  fixed  landmarks  by  which  the  location  of  organs  is 
determined.  The  student  should  familiarize  himself  with  the  shape 
of  the  bones  and  the  location  of  normal  tuberosities. 

The  bones  may  be  the  seat  of  nutritive  changes,  and  of  inflammation 
of  an  infectious  nature. 

Local  Changes.  General  changes  of  the  skeleton  have  been 
referred  to.  Local  examination  of  the  bones,  however,  is  of  the  great- 
est importance.  The  discovery  of  a  slight  change  may  lead  to  the 
recognition  of  a  grave  general  process.  We  examine  for  local  inflam- 
mation and  the  presence  of  nodes.  Simple  local  inflammation  or  peri- 
ostitis may  be  due  to  syphilis,  and  is  recognized  by  local  pain,  swelling, 
and  slight  oedema.  It  may  be  diffuse.  It  is  seen  most  frequently  on 
the  tibia,  sternum,  and  clavicle.  Nodules  or  nodes  are  usually  due  to 
syphilis.  They  form  on  various  portions  of  the  skeleton,  but  are  most 
frequently  seen  on  the  skull,  especially  on  the  forehead;  they  are  also 
found  on  the  shafts  of  the  long  bones,  preferably  the  tibia,  ulna,  and 
clavicles.  They  are  usually  multiple  or  bilateral.  They  are  painful, 
and  tender  on  jjressure.  They  are  not  so  hard  and  dense  as  exostoses. 
The  latter  are  situated  on  the  outer  aspects  of  the  bone  and  in  relation 
with  the  strongest  tendons  or  mucles. 

As  an  illustration  of  the  importance  of  recognizing  nodes  the  writer 
recalls  a  case  of  persistent  headache,  the  true  nature  of  which  was  only 
ascertained  by  finding  a  small  node  on  the  skull.  The  headache  had 
been  of  long  (five  years)  duration,  and  treatment  for  it  had  been  sought 
in  many  countries. 

Tenderness  of  the  sternum  upon  pressure  is  often  of  diagnostic  sig- 
nificance and  usually  indicative  of  syphilis.  The  pain  and  tenderness 
just  noted,  however,  must  not  be  confounded  with  local  tenderness  due 


THE  DATA  OBTAINED  BY  OBSERVATION.  143 

to  necrosis  which  often  arises  in  convalescence  from  fevers,  notably 
those  of  an  infections  nature. 

Position  and  Shape.  The  peculiar  position  (falling  downward) 
of  the  scapula  in  paralysis  of  the  serratus  magnus  is  diagnostic  of  that 
affection,  and  indicates  disease  of  the  posterior  thoracic  nerve.  In 
examination  of  the  clavicles  fractures  must  not  be  mistaken  for  dis- 
ease of  the  bones,  such  as  rickets.  The  examination  of  the  spinal 
column  is  of  the  greatest  importance.  (See  Spinal  Joints,  next  chap- 
ter.) A  study  of  the  diseases  of  the  spinal  column  due  to  caries  from 
tuberculosis  is  not  within  the  province  of  this  work;  no  physical  exam- 
ination, however,  is  complete  without  an  investigation  of  the  movability 
of  the  spine  and  the  presence  or  absence  of  curvature.  I  refer  to  the 
curvature  due  to  weakness  of  groups  of  spinal  muscles.  Functional 
disorders  of  the  gastro-intestinal  tract  and  of  the  uterus  are  undoubt- 
edly intensified  by  the  presence  of  curvature,  which  leads  to  deformity 
of  the  body,  and  hence  to  the  assuming  of  abnormal  positions  when 
sitting  or  walking.  To  recognize  lateral  or  anterior  curvature  is  to  be 
able  to  put  the  patient  on  lines  of  treatment  which  otherwise  would 
not  be  followed,  but  without  which  weak  muscles,  improper  aeration 
of  blood,  and  sluggish  circulation  would  persist.  Pain  in  the  distri- 
bution of  nerves,  or  at  their  termini,  is  often  due  to  spinal  caries  press- 
ing on  them  as  they  pass  through  the  foramina.  The  most  noticeable 
is  the  pain  about  the  umbilicus  in  children,  due  to  Pott's  disease. 

The  bones  and  cartilages  connected  with  the  thorax  will  be  consid- 
ered under  Diseases  of  the  Lungs. 

Osteomyelitis.  The  occurrence  of  high  fever,  with  or  without 
chills  but  usually  with  pysemic  symptoms,  without  recognized  cause, 
should  lead  to  an  examination  of  the  bones.  A  spot  of  tenderness  fol- 
lowed by  local  redness  and  swelling — on  the  tibia,  for  instance — would 
indicate  the  seat  of  suppuration  in  osteomyelitis. 

The  Joints.  By  inspection  and  palpation  the  changes  in  the  joints 
are  observed  which  are  of  great  significance  in  the  recognition  of 
various  morbid  processes. 

Inspection.  The  size,  shape,  and  color  are  observed,  as  well  as  the 
position  assumed.  In  addition,  the  movability  of  the  joint  is  investi- 
gated. The  number  of  joints  affected,  the  limitation  to  large  or  small 
joints,  the  occurrence  of  metastasis,  are  indications  of  the  nature  of  the 
affection.  Polyarticular  inflammation  of  small  joints  points  to  rheuma- 
toid arthritis;  of  large  joints,  to  rheumatism;  monarticular  inflamma- 
tion of  small  joints,  to  gout;  of  large  joints,  to  gonorrhoeal  rheumatism 
or  pyaemia;  sudden  flitting  from  one  joint  to  another  is  characteristic 
of  rheumatism. 

The  Size  and  Shape.  The  joints  may  be  enlarged.  The  enlarge- 
ment may  be  due  to  infiltration  of  the  tissues  about  the  joints,  to  effu- 
sion within  the  joints,  serous  or  purulent,  or  to  inflammation  of  the 
ends  of  the  bones. 

1.  When  the  enlargement  is  due  to  infiltration  about  the  joint,  the 
tissues  are  previously  thickened,  as  shown  by  palpation,  and  the  outline 
of  the  joint  is  changed.      The  normal  contour  is  lost  entirely,  and, 


144  GENERAL  DIAGNOSIS. 

instead,  there  is  a  globular  swelling  beginning  above  and  extending 
below  the  joint.  2.  When  the  enlargement  is  due  to  effusion  it  may  be 
detected  by  palpation,  as  this  secures  fluctuation.  This  is  particularly 
so  in  the  large  joints.  If  the  joint  involved  is  the  knee,  the  patella  will 
float.  The  effusion  changes  the  normal  contour,  but,  in  the  earlier 
stages,  may  cause  local  swellings  where  the  synovial  sacs  are  near  the 
surface  ;  hence,  at  the  articulation  of  the  tibia  and  fibula  with  the  tar- 
sus, on  the  inner  and  outer  side,  a  boggy  swelling  is  observed.  At 
the  knee  the  swelling  is  on  each  side  above  and  below  the  patella. 
When  the  effusion  is  great  the  joint  becomes  immobile,  and  may  be 
flexed  from  distention  of  the  sac.  3.  When  enlargement  of  the  joints 
is  due  to  hypertrophy  of  the  bones,  the  latter  are  thickened  and  very 
hard.  There  may  or  may  not  be,  and  usually  is  not,  fixation,  and 
mo.vement  is  but  moderately  interfered  with. 

Changes  in  the  outline  of  the  joint  are  also  seen  in  rheumatoid  arth- 
ritis. The  loss  of  the  cartilaginous  substance  of  the  joint,  with  the 
secondary  osteophytic  changes,  causes  deformity,  so  that  in  the  case 
•of  the  small  joints  of  the  finger  subluxation  is  seen;  similar  subluxa- 
tions are  seen  in  larger  joints.  The  ends  of  the  phalangeal  bones  are 
thickened.  Change  in  the  color  is  usually  noticed  in  inflammations. 
The  surface  is  either  bright  red  or  dusky. 

The  position  assumed  is  of  diagnostic  importance.  Flexion  of  the 
limb  of  the  affected  joint  occurs  in  overdistention.  In  rheumatoid 
arthritis  there  is  subluxation.     Immobility  is  observed  (see  Palpation). 

Palpation.  The  results  of  inspection  are  confirmed.  1.  The 
movability  of  the  joint  is  learned.  Movement  is  inhibited  in  inflam- 
mation on  account  of  the  pain.  A  reflex  muscular  spasm  takes  place 
if  osteitis  and  cartilage-destruction  are  present.  The  spasm  prevents 
movement.  In  effusion  there  is  less  movability  or  even  none  at  all. 
In  rheumatoid  arthritis  movement  is  prevented  by  the  osteophytic 
growths  which  surround  the  joint. 

2.  Fluctuation  is  revealed  by  palpation,  pointing  to  liquid  effusion 
within  the  joint.  (Edema  of  the  surrounding  tissues  occurs  in  purulent 
effusions. 

3.  A  crepitus  or  grating  sensation  is  observed  in  rheumatoid  arth- 
ritis and  other  destructive  diseases. 

The  subjective  symptoms  of  joint-affections  are  worthy  of  note.  Pain 
is  the  most  prominent.  This  may  be  spontaneous,  or  may  arise  upon 
pressure,  or  follow  attempts  at  movement.  Spontaneous  pain  with  ten- 
derness is  more  pronounced  in  rheumatic  and  gouty  inflammations  of 
the  joints.  The  pain  is  usually  worse  at  night.  This  is  particularly 
the  case  in  tuberculous  joints,  and  is  due  to  removal  of  the  apprehensive 
spasm  of  the  muscles  whereby  the  joints  had  been  protected. 

Pain  in  the  joints  must  not  be  confounded  with  that  of  local  or 
multiple  neuritis.  I  have  seen  the  pains  of  neuritis  attributed  to  rheu- 
matism of  the  phalanges,  tarsus,  and  ankle,  until  paralysis  of  the  exten- 
sors took  place.  I  have  seen  the  pain  of  neuritis  of  the  circumflex 
mistaken  lor  shoulder-joint  disease.  Multiple  neuritis  is  attended  by 
pains  that  may  be  located  in  the  joints  by  the  patient;  but  neither  in 


THE  DATA   OBTAINED  BY  OBSERVATION.  145 

local  nor  in  general  neuritis  are  the  joints  ever  swollen,  tender,  or 
painful  on  passive  movement. 

The  Joints  of  Rh  a  otitis  (see  under  Rhachitis). 

The  Joints  of  Osteo-arthritis  (see  under  Skeleton). 

The  Joint  of  Synovitis.  The  inflammation  is  recognized  by 
pain,  heat,  redness,  and  swelling.  Effusion  is  present,  and  its  physical 
signs  are  readily  elicited.  It  may  be  due  to  traumatism,  but  we  are 
chiefly  concerned  with  inflammations  due  to  internal  morbid  processes. 
When  single  joints  are  affected  the  most  common  causes  are  tubercu- 
losis, pyaemia,  and  gonorrhoeal  infection.  A  mild  degree  of  inflamma- 
tion may  be  limited  to  one  joint  in  subacute  rheumatism.  When  many 
joints  are  affected  the  cause:  is  an  infectious  one,  as  rheumatism,  sep- 
ticaemia, pyaemia,  epidemic  cerebro-spinal  meningitis,  scarlet  fever,  and 
dysentery,  rarely  gonorrhoea.  The  joints  are  swollen  and  red.  Peri- 
aud  intra-articular  effusions  occur.  In  tuberculosis  the  joint  is  swollen 
and  the  neighboring  tissues  oedematous.  Effusion  may  be  detected. 
There  is  fever.  The  hip,  the  knee,  the  elbow,  the  wrist,  and  the 
ankle  are  most  frequently  affected.  Cheesy  material  may  be  with- 
drawn by  tapping.  Destruction  ultimately  takes  place,  with  subluxa- 
tions and  subsequent  fixation  of  the  joint.  With  the  fever,  wasting, 
and  other  signs  of  tuberculosis,  its  presence  in  some  other  portions  of 
the  body  points  to  the  true  nature  of  the  affection.  The  tuberculous 
process  may  be  limited  to  the  affected  joint,  or  secondary  tuberculosis 
may  supervene. 

The  Joint  of  Gonorrhceal  Rheumatism.  The  knee-joint  is 
usually  affected.  Signs  of  acute  or  subacute  inflammation  are  present 
with  oedema  and  effusion.  The  patient  is  a  male  in  whom  an  acute  or 
chronic  urethral  discharge  is  found.  The  pain  is  worse  at  night. 
The  process  is  of  long  duration.  Metastasis  does  not  take  place. 
Destruction  rarely  occurs,  but  ankylosis  may.  General  pysemic  symp- 
toms may  ensue,  and  gonorrhoeal  endocarditis  supervene.  The  micro- 
organisms (gonococci)  can  be  found  in  the  blood  and  the  pus  of  the 
affected  joint.  There  is  entire  absence  of  heart-symptoms  from  simple 
endocarditis.  The  general  and  local  signs  of  rheumatism  or  of  a  rheu- 
matic diathesis,  and  changes  in  the  urine,  skin  eruptions,  cardiac  lesions, 
etc.,  are  wanting.  In  certain  cases  many  joints  are  affected,  but  the 
temperature  is  not  so  high  or  the  sweats  so  pro  fuse  as  in  acute  rheumatism. 

The  Joint  of  Gout.  Any  joint  may  be  affected,  but  the  typical 
gouty  inflammation  is  seen  in  the  metacarpophalangeal  joint  of  the 
great  toe — the  ball  of  the  toe.  There  is  great  swelling,  intense  red- 
ness, enlargement  of  the  veins,  and  oedema.  There  may  be  some  effu- 
sion; it  results  in  chronic  inflammation  and  enlargement  of  the  joint. 
Tophi  about  the  joints  are  observed.  Agonizing  pain  occurs,  and  is 
worse  at  night.  It  is  characteristic  of  the  attack  that  it  comes  on  sud- 
denly and  at  night.  Fever  attends  the  process.  The  attack  is  of 
short  duration,  and  may  be  followed  or  attended  by  acute  gouty  inflam- 
mation of  other  structures,  or  by  vascular  and  renal  changes  associated 
with  this  general  morbid  process. 

The  Joint  of  Rheumatism.  It  is  swollen,  painful  both  sponta- 
neously and   on    movement,  and   there  may  be  some  redness  of  the 

10 


146  GENERAL  DIAGNOSIS. 

surface.  Other  joints  are  soon  attacked,  with  subsidence  of  the 
symptoms  in  the  joint  originally  attacked.  The  large  joints  are  usually 
affected.  It  may  be  limited  to  one  side  or  may  affect  both.  Second- 
ary or  concurrent  cardiac  inflammations  may  be  noted.  High  fever 
and  acid  sweats  attend  the  process,  which  is  common  in  both  sexes  in 
childhood  and  early  adult  life.  Other  evidences  of  the  rheumatic 
diathesis  and  the  history  of  previous  attacks  point  to  the  true  nature 
of  the  joint-swelling. 

The  Joint  of  Rheumatoid  Arthritis.  There  may  be  simple 
chronic  inflammation  with  acute  exacerbations,  or  prolonged  subacute 
inflammation.  The  small  joints  are  affected  first,  as  the  phalanges. 
They  are  swollen  and  the  adjacent  structures  infiltrated.  At  first  there 
may  be  some  effusion  increasing  with  each  exacerbation.  Later  the 
cartilages  are  eroded,  and  crepitus  and  grating  are  detected  on  palpa- 
tion. Subluxation  with  great  deformity  ensues,  followed  by  complete 
fixation  of  the  joint.  The  crepitation  may  be  detected  along  the  sheaths 
of  the  tendon.  Osteophytes  develop.  The  skin  over  the  surface 
becomes  glossy,  and  the  affected  hands  are  covered  with  freckles. 
Occurring  in  early  adult  life,  usually  in  females  with  marked  anaemia 
and  secondary  wasting  of  the  muscles,  without  heart-lesion  or  general 
indications  of  rheumatic  or  gouty  diathesis,  the  true  nature  of  the 
swelling  is  easily  recognized.  (See  Rheumatoid  Arthritis — Extrem- 
ities. ) 

The  Tabetic  Joint.  In  forms  of  nervous  diseases,  particularly 
in  sclerosis  of  the  posterior  columns,  secondary  joint-involvement 
sometimes  occurs.  The  change  in  the  large  joints  is  preceded  by 
pain,  stiffness,  and  inability  to  use  them.  Gradually  nutritive  changes 
take  place.  At  first  there  is  boggy  swelling.  The  cartilages  become 
eroded,  the  heads  of  the  bone  waste,  the  ligaments  ossify,  and  irreg- 
ular bony  growths  project.  Wasting  of  the  head  of  the  femur  is  fol- 
lowed by  dislocation.  Sometimes  an  effusion  takes  place  in  the  joints, 
and  there  may  be  peri-articular  oedema.  The  large  joints  are  most 
commonly  affected — the  knee,  hip,  ankle,  and  elbow.  Injury  excites 
the  abnormal  atrophic  process.  When  the  tarsal  bones  and  the  articu- 
lations are  affected  the  foot  becomes  flat,  and  the  tarsal  and  metatarsal 
articulation  and  the  tarsal  bones  project  forward  or  backward.  This 
is  called  the  tabetic  foot. 

The  Joint  of  Hysteria.  Symptoms  of  joint-disease  are  seen 
in  hysteria.  Pain  and  fixation  of  the  joint  are  sometimes  complained 
of.  The  joint  rarely  undergoes  organic  changes,  but  sometimes  a 
plastic  infiltration  of  the  connective  tissue  outside  of  the  capsule  does 
occur.  The  hysterical  nature  of  the  pain  and  immobility_are  recog- 
nized by  the  absence  of  a  cause  for  joint-lesion,  the  absence  of  fluctua- 
tion, or  of  signs  due  to  erosion,  by  the  association  of  the  local  symptoms 
with  the  phenomena  of  hysteria,  but,  jmore  particularly,  by  the  fact 
that  contraction  and  even  wasting  precede  the  joint-symptoms.  In 
true  affections  of  the  joint  both  occur  after  the  joint  has  become  dis- 
eased; in  hysteria  muscular  contraction  will  take  place  first. 

The  knee  is  the  joint  usually  affected.  Care  must  be  taken  not  to 
be  deceived  by  local  vasomotor  changes  of  hysterical  origin  which  may 


THE  DATA  OBTAINED  BY  OBSERVATION.  147 

be  observed  over  the  surface  of  the  joint.  This  local  increased  tem- 
perature is  not  associated  with  general  fever,  however,  while  the  vaso- 
motor changes  indicated  by  the  swelling  of  the  skin,  increased  tension, 
and  the  shining  appearance,  with  increased  sensibility,  are  not  persis- 
tent, but  occur  once  or  twice  in  the  twenty- four  hours.  In  a  remark- 
able case  of  Mitchell's  the  local  vasomotor  change  took  place  at  night. 
The  temperature  of  the  knee  which  was  affected  increased  three  or 
four  degrees,  while  the  pulse  remained  at  80.  The  local  symptoms 
of  heat,  redness,  swelling,  tension,  and  increased  pain  passed  away  by 
three  o'clock  in  the  morning.  The  fact  that  the  same  symptoms  could 
be  brought  on  by  handling  the  knee,  or  by  pressure  upon  the  patella, 
pointed  to  its  vasomotor  origin. 

In  joint-cases  of  hysterical  origin  the  reflexes  must  be  studied.  They 
do  not  change,  and  the  electrical  reactions  are  normal,  although  there 
may  be  atrophy  from  disuse,  but  not  to  the  degree  that  occurs  in  organic 
disease.  The  muscles  may  be  contracted,  but,  as  previously  noted,  the 
contracture  is  primarily  a  relaxation,  which  takes  place  if  the  tension 
is  removed.  Concerning  these  vasomotor  changes,  Sir  James  Paget' s 
expression,  "A  joint  which  is  cold  by  day  and  hot  by  night  is  not  an 
inflamed  joint,"  is  a  safe  guide  to  the  recognition  of  an  hysterical  joint- 
When  the  joint  becomes  hysterical  after  injury  it  is  most  difficult  to^ 
ascertain  its  true  nature. 

Special  Joints.  The  three  joints  that  should  concern  the  student 
more  particularly  are  the  shoulder,  hip,  and  knee.  When  symptoms 
are  referred  to  either  of  these  joints  they  should  not  be  passed  over 
lightly.  Grave  consequences  have  followed  the  attributing  of  hip- 
joint  inflammation  to  rheumatism,  when  it  was  of  tuberculous  origin. 
Not  only  has  hip-joint  disease  been  mistaken  for  rheumatism,  but  the 
mistake  has  even  been  made  of  considering  the  process  to  be  going  on 
in  the  knee  instead  of  in  the  hip.  This  is  because  there  is  often  flexion 
of  the  leg,  and  because  pain  is  so  often  referred  to  the  knee-joint. 

On  the  other  hand,  cases  of  hip-joint  disease  have  been  mistaken 
for  suppuration  in  the  pelvis  or  in  the  iliac  fossa.  Typhlitis  or  appen- 
dicitis has  frequently  been  mistaken  for  hip-joint  disease. 

In  the  case  of  the  shoulder-joint  there  is  danger  of  confounding 
neuritis  of  the  circumflex  nerve,  and  consequent  paralysis  of  the  del- 
toid, with  affections  of  the  joint.  Although  the  patient  is  unable  to 
move  the  joint,  it  is  still  readily  moved  by  the  physician,  and  the 
physical  signs  of  joint-inflammation  are  wanting. 

Method  of  Examination.  When  the  bones  and  joints,  especially 
the  spinal  column,  are  to  be  examined,  the  patient  should  be  stripped, 
and  after  the  movements  and  positions  in  the  upright  or  semi-upright 
position  have  been  noted,  he  should  be  made  to  lie  down  on  a  hard, 
smooth  surface,  and  the  trunk  and  joints  examined  in  that  position. 
Anterior,  posterior,  and  lateral  movements  of  the  spinal  column  must  be 
made  to  determine  its  flexibility.  In  this  manner  deformities,  changes 
in  the  length  of  the  bones,  and  abnormal  posture  can  be  carefully 
observed.  In  addition  we  must  note  muscular  wasting,  the  presence 
of  local  tenderness  and  swelling,  changes  in  the  movements  of  the 


148     '  GENERAL  DIAGNOSIS. 

joints,  and  loss  of  other  functional  activity  causing  lameness  or  joint- 
disability. 

Factors  of  Diagnostic  Significance.  The  distribution  of  the 
lesion  in  joint-affections  is  of  great  diagnostic  significance.  Lesions 
may  be  unilateral  or  bilateral,  and  may  be  symmetrical  or  asymmet- 
rical. They  may  be  limited  to  the  small  or  to  the  large  joints.  Bilat- 
eral joint-lesions  are  characteristic  of  rheumatoid  arthritis.  In  this 
disease,  moreover,  the  small  joints  are  chiefly  involved.  In  gout  the 
small  joints  are  primarily  affected,  though  the  large  joints  may  become 
affected  secondarily.  In  rheumatism,  on  the  other  hand,  larger  joints 
are  first  involved.  This  affection  is  characterized  by  the  occurrence 
of  asymmetrical  inflammation  in  many  joints,  the  irregularity  of  its 
distribution  and  the  fngaceous  nature  of  the  joint-affections.  Mon- 
articular inflammation  is  usually  seen  in  gonorrhoeal  rheumatism.  In 
pyaemia  the  large  joints  are  involved.  The  range  of  movement  and 
the  data  obtained  by  palpation  are  not  of  marked  diagnostic  signifi- 
cance. In  all  joint-affections  movement  whether  active  or  passive  is 
limited  and  painful. 


CHAPTER  IV. 

BACTERIOLOGICAL  DIAGNOSIS. 

Causal  relation  of  bacteria  to  disease.  Koch's  laws;  value  in  diagnosis.  Method 
of  research :  Microscopical  examination,  cultivation,  inoculation.  Essentials 
in  technique — Bacteria:  Saprophytes,  parasites,  pathogenic,  non-pathogenic, 
aerobic,  anaerobic,  facultative  anaerobic.  Morphology :  Micrococci,  bacilli, 
spirilla. — Micrococci.  Morphology :  Form  and  size.  Reproduction,  fission  ; 
grouping.  Biological  characters :  Non-motile.  Pigment-production.  Lique- 
faction of  gelatin.  Production  of  acids.  Toxic  ptomaines  and  toxalbumins — 
Bacilli.  Morphology  :  Form  and  size.  Reproduction,  fission,  spores  ;  grouping. 
Biological  characters  :  Motility.  Pigment-production.  Liquefaction  of  gelatin. 
Production  of  acids.  Putrefaction,  fermentation  Spirilla.  Morphology:  Form 
and  size.  Reproduction,  fission  ;  grouping.  Biological  characters.  Motility. 
Pigment-production.  Liquefaction  of  gelatin  Production  of  acids  and  fer- 
mentation wanting. — Method  of  research:  Blood,  discharges,  exudations ;  mode 
of  collection.  Apparatus.  Preparation  of  apparatus.  Sterilization.  Microscopi- 
cal examination  :  Technique,  cover-glass  preparations.  Methods  of  staining ; 
spores.  "Hanging  drop." — Cultivation  of  micro-organisms.  Culture-media. 
Tube-  and  plate-cultures.  Smear-  and  stab  cultures  — Inoculation  of  animals. — 
Special  bacteriological  diagnosis. 

It  had  long  been  surmised  that  micro- organisms  had  much  to  do 
with  morbid  processes,  and  that  the  relationship  was  that  of  cause  and 
effect.  It  was  known,  for  instance,  that  suppuration,  surgical  lever, 
erysipelas,  hospital  gangrene,  and  puerperal  fever  were  associated  with 
conditions  which  favored  the  multiplication  of  the  lower  forms  of  life. 
What  relationship  the  micro-organisms  bore  to  the  various  affections 
Avas  not  known.  Least  of  all  were  the  specific  micro-organisms  which 
were  the  causes  of  particular  specific  morbid  processes  known.  I  have 
said  that  it  was  surmised;  but  there  was  groping  about,  a  difference 
of  opinion,  and  a  maximum  of  theory,  a  minimum  of  fact.  It  is 
true  that  in  relapsing  fever  the  spirillum  had  been  found,  and  that 
none  had  been  found  in  any  other  disease. .  Moreover,  it  is  true  that 
monkeys  had  been  inoculated  and  the  disease  reproduced  in  them.  It 
is  true  that  the  bacillus  of  anthrax  had  been  seen  in  the  blood,  in  the 
early  sixties.  It  is  true  that  the  great  genius  Pasteur  had  prosecuted 
studies  of  bacteria  in  animal  and  vegetable  pathology  to  most  brilliant 
and  practical  conclusions.  Nevertheless,  there  were  confusion  and 
doubt  ;  scientists  were  not  satisfied  with  the  demonstrations  which 
undertook  to  prove  the  causal  relationship  of  micro-organisms  t<> 
disease. 

Laws  to  Establish  Causal  Relationship.  By  the  genius  of 
Robert  Koch  theories  and  objections  were  set  at  naught.  The  scien- 
tific world  was  fully  prepared  by  the  labors  of  early  investigators  t<» 


150  GENERAL  DIAGNOSIS. 

accept  Koch's  conclusions.  They  were  based  upon  an  array  of  well- 
authenticated  facts,  which  anyone  could  prove  for  himself.  The  pos- 
tulates formulated  by  Koch,  the  fulfilment  of  which  he  considered  as 
necessary  in  order  to  identify  an  organism  as  the  etiological  factor  in 
a  given  disease,  are  as  follows  :  The  constant  presence  of  the  organism 
in  the  affected  tissue  of  the  diseased  animal;  its  isolation  from  the 
pathological  lesions,  and  its  continuous  cultivation  in  pure  cultures 
under  artificial  conditions  through  many  generations;  the  power  of 
such  pure  cultures  to  reproduce  the  disease  when  inoculated  into  sus- 
ceptible animals;  and  the  detection  of  the  organism  in  pure  culture 
in  the  lesion  found  in  the  animal  thus  inoculated.  The  experimental 
circle  was  then  repeated.  In  this  manner  the  causal  relationship  of 
micro-organisms  to  special  diseases  had  been  proved  by  the  distin- 
guished investigator  in  the  case  of  anthrax,  tuberculosis,  and  other 
affections.  In  a  certain  number  of  cases  particular  species  of  bacteria 
and  other  micro-organisms  have  been  isolated  from  definite  diseases 
and  reasonably  believed  to  stand  in  causal  relation  to  them,  but  which 
have,  nevertheless,  not  fulfilled  all  the  requirements  of  the  above- 
cited  postulates.  The  difficulties  often  encountered  are  :  The  faithful 
reproduction  in  animals  of  the  clinical  and  pathological  features  that 
the  diseases  present  in  human  beings,  as  is  the  ca-e  with  typhoid  fever, 
influenza,  gonorrhoea,  and  fibrinous  or  lobar  pneumonia;  and  the  im- 
possibility of  satisfactorily  cultivating  certain  other  organisms  that  are 
the  constant  accompaniment  of  particular  diseases  of  man,  as,  for 
instance,  the  plasmodium  malaria?,  and  the  bacillus  of  syphilis,  and 
the  amoeba  coli. 

Aid  to  Diagnosis.  It  is  readily  seen  that  when  the  definite  cause 
of  an  infectious  disease  is  isolated,  and  the  morphological  and  biological 
properties  of  the  causal  micro-organism  determined,  the  clinician  has 
acquired  a  valuable  aid  to  diagnosis.  Indeed,  in  such  affections  the 
bacteriological  diagnosis  has  become  an  absolute  certainty. 

Method  of  Research.  The  diagnosis,  to  be  complete,  must  include 
(1)  the  finding  of  the. specific  micro-organism  in  the  blood. or  tissues 
(of  the  subject)  or  in  the  pathological  secretions  or  excretions;  (2)  the 
isolation  and  cultivation  of  the  micro-organism;  (3)  the  inoculation  and 
the  reproduction  thereby  of  the  disease  in  animals.  In  many  affections 
the  morphological  peculiarities  of  the  micro-organism  are  so  character- 
istic that  by  this  alone  a  diagnosis  may  be  established.  On  the  other 
hand,  in  some  affections,  the  absence,  or  rather  failure  of  detection, 
of  the  micro-organism  in  the  fluids  or  discharges  is  not  proof  that  the 
disease  is  not  preseut  in  the  suspected  individual,  when  symptoms  and 
lesions  point  to  a  specific  micro-organism.  The  affection  tuberculosis 
well  illustrates  the  propositions  in  the  last  two  sentences.  If  the  bacillus 
is  found  in  the  sputum  of  a  suspected  case,  the  diagnosis  is  established 
definitely,  and  no  further  procedures  for  diagnostic  purposes  are  neces- 
sary. In  other  clinical  forms,  as  tuberculous  pleurisy,  or  empyema, 
or  glandular  or  joint  tuberculosis,  the  micro-organisms  are  few  and 
difficult  to  find.      Cultures,  or,  more  conclusive  still,  inoculations,  must 


BA  GTEBIOLOGICAL  DIAGNOSIS.  151 

frequently  be  resorted  to  before  a  final  conclusion  can  be  arrived  at. 
It  is  possible  that  spores  alone  exist — morphological  elements  difficult 
to  detect  by  staining  and  microscopical  methods,  but  which  may  rapidly 
multiply  under  favorable  culture-  or  inoculation-conditions.  Again, 
micro-organisms  have  been  found  in  certain  affections,  and  although 
thus  far  their  causal  relationship  to  them  has  not  been  fully  proved, 
nevertheless  their  constant  occurrence  in  the  special  affection,  and  in  it 
alone,  renders  their  presence  of  high  diagnostic  value.  Thus  the 
amoeba  of  dysentery  and  the  plasmodium  malarias  of  Laveran  are 
diagnostic  of  their  respective  affections. 

Essential  Knoidedge.  For  diagnostic  purposes  bacteriological  inves- 
tigations must  be  conducted  in  accordance  with  the  methods  of  bacte- 
riology. Such  researches  are  possible  at  this  time,  because  of  (1)  the 
high  degree  of  development  and  mode  of  use  of  optical  apparatus, 
including  oil-immerson  lenses,  Abbe's  condenser,  and  diaphragms  ; 
(2)  the  discoveries  by  Weigert  of  the  effects  of  aniline  dyes  on  proto- 
plasm, and  the  property  of  micro-organisms  of  taking  different  stain- 
ings;  (3)  of  the  principles  of  sterilization  by  heat,  by  which  foreign 
micro-organisms  are  excluded;  (4)  of  the  use  of  solid  culture-media, 
and  the  plate-method  of  obtaining  pure  cultures  suggested  by  Koch. 

Bacteria.  Varieties.  Bacteria  are  of  two  classes.  One  class 
obtain  subsistence  from  dead  organic  matter,  breaking  it  up  into  such 
simpler  forms  as  carbon  dioxide,  ammonia,  etc.  They  act  to  some 
extent  as  scavengers,  and  are  beneficial  rather  than  harmful.  Such 
are  called  saprophytes.  The  second  class  live  at  the  expense  of  higher 
forms  of  life,  and,  at  the  same  time,  produce  very  poisonous  substances. 
They  are  called  parasites,  and  are  or  are  not  essentially  harmful.  We 
are  concerned  with  the  harmful  varieties.  They  imply  the  presence 
of  a  host  in  which  they  develop.  Diseases  to  which  they  give  rise  are 
known  as  infectious  diseases.  The  process  they  set  up  may  be  local,  as 
in  gonorrhoea  or  certain  skin  affections,  or  general,  as  in  typhoid  fever, 
syphilis,  or  tuberculosis.  In  some  instances  it  is  first  local  and  then 
becomes  general,  as  in  tuberculosis.  Their  clinical  manifestation  is 
seen  in  the  infectious  diseases.  Sometimes  certain  bacteria  of  one  class 
may  acquire  the  power  of  living  like  those  of  the  other  class,  and  are 
then  called  facultative  saprophytes  or  parasites.  They  develop  in  cav- 
ities of  the  body.  They  may  enter  the  blood.  They  produce  in  cer- 
tain cases  particularly  poisonous  substances  which  enter  the  circulation 
and  cause  an  intoxication,  to  which  the  term  saprcemia  or  toxaemia  is 
applied  Parasites  and  facultative  parasites  include  those  bacteria  that 
arc  productive  of  disease,  and  are  therefore  known  as  pathogenic  bac- 
teria.  All  bacteria  require  certain  conditions  and  certain  materials  for 
their  development.  All  require  carbon,  nitrogen,  and  water,  and  a 
certain  temperature,  which  varies  in  each  case.  Some  require  oxygen 
and  are  called  aerobic;  others  cannot  grow  in  the  presence  of  oxygen, 
and  are  called  anaerobie.  Others  grow  either  with  or  without  oxygen ; 
these  are  called  facultative  anaerobic. 

Morphology  and  Biological  Characteristics.  To  determine 
the  micro-organisms  which  may  be  the  cause  of  the  disease  under  exam- 


152  GENERAL  DIAGNOSIS. 

ination  the  student  must  be  familiar  with  the  morphology  and  biological 
properties  of  the  various  forms.  (By  means  of  this  knowledge  a  bac- 
teriological diagnosis  is  made.)  The  morphology.  The  shape,  the  size, 
the  mode  of  reproduction  and  grouping  are  to  be  studied.  Bacteria  or 
fungi  are  divided  morphologically  into  micrococci  or  spherical  bacteria, 
bacilli  or  rod-shaped  bacteria,  and  spirilla  or  twisted  forms.  Bacteria 
procreate  by  simple  fission,  and  are  therefore  known  as  fission-fungi  or 
schizomycetes.  Some  forms  also  produce  spores.  The  biological  prop- 
erties include  motility,  color,  the  growth  on  various  culture-media  and 
under  various  temperatures,  and  the  product  of  vital  activity.  The 
growth  on  various  culture-media  will  be  considered  under  each  patho- 
genic bacterium  which  it  is  the  province  of  this  work  to  discuss.  On 
the  character  and  extent  of  this  growth,  its  color  and  other  properties, 
data  are  collected  by  which  the  various  micro-organisms  are  distin- 
guished. Some  properties  which  do  not  belong  to  pathogenic  bacteria 
will  not  be  considered,  as  the  production  of  phosphorescence,  the  pro- 
duction of  marsh  gas,  hydrosulphuric  acid,  viscous  fermentation,  and 
the  fermentation  of  urea. 

By  the  above  means  we  can  sufficiently  identify  the  pathogenic  bac- 
teria for  our  present  purpose. 

Micrococci.  Morphology.  To  this  group  belong  the  spherical 
bacteria,  Each  coccus  is  of  nearly  equal  diameter  in  all  directions. 
They  vary  in  size  from  0.1//  to  1  or  2/j..  A  micromillimetre  (//)  is  one 
twenty-five-thousandths  of  an  inch.  The  various  micrococci  resemble 
each  other  so  much  in  form  and  size  that  they  cannot  be  distinguished 
by  their  microscopic  appearances.  To  distinguish  them  we  depend  on 
the  color  and  character  of  their  growth  in  various  culture-media,  on 
their  pathogenic  power,  and  on  other  biological  differences.  The  mode 
of  grouping,  after  fission  or  reproduction,  is  an  important  characteristic 
by  which  varieties  are  differentiated.  Just  before  dividing  they  are  not 
perfectly  spherical,  but  short  or  long  oval.  After  division  (for  they 
divide  indefinitely  when  groAving)  the  staphylococci  are  solitary  or  in 
pairs,  or,  occasionally,  in  groups  of  four,  or  in  clusters  roughly  likened 
to  a  bunch  of  grapes,  from  which  latter  grouping  they  derive  their  name. 
The  organism  is  called  a  diplococcus  when  associated  in  pairs.  Some- 
times two  or  four  are  included  in  a  capsule.  Zooglosce  are  groups  of 
cocci  held  together  by  a  transparent  glutinous  substance.  Streptococci 
are  characterized  by  a  grouping  in  chains,  known  aschaplefs  or  torula 
chains,  because  division  takes  place  in  one  direction  only.  When  divi- 
sion takes  place  in  two  directions,  groups  of  four,  or  tetrads,  are  formed  ; 
and  when  in  three  directions,  groups  or  packets  of  eight  are  formed, 
of  which  the  sarcince  are  the  most  familiar  examples.  The.se  names, 
significant  of  the  grouping,  refer  to  the  predominating  groups  as  seen 
in  microscopic  preparations.  In  some  of  such  groups,  for  instance,  are 
seeu  only  diplococci,  or  streptococci;  but  in  all  transitional,  irregular, 
aud  accidental  groupings  may  be  observed. 

Biological  Characteristics.  Micrococci  are  not  motile  and  do 
not  form  spores.  Products  of  vital  activity.  The  various  forms  of 
bacteria  are  also  distinguished  by  noting  the  difference  in  the  products 
of  vital  activity.      Of   these,  pigment-production  is  one  of   the  most 


BA  CTERIOL  0  GIGA  L  DIA  G  NOSIS.  1 5  3 

apparent.  The  staphylococcus  pyogenes  aureus  and  citreus  are  chromo- 
genic  or  pigment-producing  bacteria.  The  liquefaction  of  gelatin,  when 
cultures  are  made,  is  a  biological  characteristic  which  assists  the  diag- 
nosis of  the  various  species.  Some  pathogenic  as  well  as  non-pathogenic 
germs  have  this  effect  on  the  nutrient  medium  ;  others  of  both  classes 
do  not  affect  it.  A  peptonizing  ferment  is  formed  during  the  growth 
of  cells  which  acts  upon  and  dissolves  the  gelatin.  The  amount, 
degree,  and  character  of  liquefaction  serve  to  distinguish  various  species. 
The  staphylococcus  pyogenes  aureus  and  albus  (as  well  as  some  others) 
are  liquefying  micrococci.  Production  of  acids.  Many  bacteria  pro- 
duce an  acid — lactic  acid,  acetic  acid,  butyric  acid — which  gives  an 
acid  reaction  to  the  culture-media.  This  may  be  seen  if  a  neutral 
litmus  solution  has  been  added  to  the  gelatin.  The  pink  color  produced 
indicates  the  presence  of  an  acid.  Culture-media,  it  must  be  remem- 
bered, are  alkaline  or  neutral.  The  pathogenic  micrococci  which  pro- 
duce an  acid  are  the  staphylococci  of  pus — lactic  acid. 

Putrefactive  fermentation  is  set  up  by  bacilli  and  not  by  micrococci. 
Other  products  of  vital  activity  need  not  concern  us,  as  they  are 
produced  by  non-pathogenic  forms. 

Toxic  ptomaines  and  toxalhumins  are  products  of  many  forms  of 
pathogenic  bacteria,  and  cause  the  symptoms  of  infective  diseases  in 
many  instances;  thus  in  diphtheria  the  local  infective  inflammation  rep- 
resents the  seat  of  activity  of  the  bacillus,  the  point  at  which  its  poisons 
are  being  manufactured  at  the  expense  of  the  tissues  in  and  on  which 
it  is  growing  ;  the  general  symptoms  are. due  to  the  toxalbumin  that 
has  been  absorbed  by  the  circulating  fluids  from  this  local  seat  of  action. 
The  isolation  and  detection  of  the  toxalbumins  are  not  sufficiently  easy 
to  warrant  such  a  mode  of  investigation  for  diagnostic  purposes.  Often 
the  results  of  inoculation,  by  which  the  lethal  effect  is  produced,  aid 
in  the  diagnosis  of  the  suspected  ailment.     (See  Plate  II.,  Fig.  2,  b.)- 

The  Bacilli.  Moephologv.  The  bacilli  or  rod-shaped  bacteria 
differ  widely  in  form,  in  size,  and  in  modes  of  grouping  after  fission. 
Form  and  size.  The  longitudinal  diameter  is  greater  than  the  trai in- 
verse, and  the  forms  vary  from  short  oval  or  slender  rods  to  long 
filaments;  sometimes  short  rods  and  long  filaments  are  seen  in  pure 
cultures  of  the  same  bacillus,  as  in  the  typhoid  bacillus.  The  trans- 
verse diameter  of  a  given  species  does  not  vary,  as  a  rule.  The  form 
of  the  extremities  of  the  rods  must  be  observed.  They  may  be  square, 
slightly  rounded,  round,  oval,  or  lance-  or  spindle-shaped.  Reproduc- 
tion and  grouping.  Fission  or  reproduction  takes  place  by  binary 
division,  transverse  to  the  longitudinal  axis.  They  group  in  long 
chains,  or  are  solitary,  or  united  in  pairs.  They  may  be  surrounded 
by  a  capsule  or  collect  in  zoogloea  masses. 

Spores.  When  conditions  unfavorable  to  continuous  multiplication 
by  transverse  division  arise  certain  bacilli  possess  the  property  of 
entering  into  a  permanent  or  resting  stage.  In  this  ease  there  develops 
within  the  body  of  the  bacillus  an  oval,  egg-shaped  structure — an 
endogenous  spore.  The  spore  represents  the  inactive  stage,  and  lies 
dormant    until    circumstances   favorable  to  growth   reappear,   when   it 


154  GENERAL  DIAGNOSIS. 

develops  into  a  bacillus  identical  with  that  from  which  it  was  formed. 
Spores  do  not  develop  into  spores,  but  into  bacilli.  The  spores  retain 
their  vitality  for  mouths  or  years,  and  resist  desiccation.  They  are 
spherical  or  oval,  and  highly  reproductive.  They  are  formed  by  con- 
densation of  protoplasm  at  the  ceutre  or  at  oue  end  of  the  bacillus, 
where  they  are  retained  in  a  linear  position  until  set  free.  Some  bacilli 
grow  into  long  filaments  during  spore- formation  ;  others  change  their 
shape,  swelling  at  the  centre,  becoming  spindle-  or  club-shaped,  accord- 
ing to  the  location  of  the  spore  within  it.  Mauy  bacilli  do  not  change 
their  shape  at  this  stage.  The  spores  are  free  or  collected  in  masses  with 
the  bacilli  as  well  as  located  in  the  parent  bacillus. 

Motility.  The  bacilli  are  often  actively  motile,  because  of  the  pres- 
ence of  flagella.  The  movement  is  one  of  progression  in  different 
directions.  It  may  be  slow  and  deliberate,  in  a  to-and-fro  motion,  or 
serpentine,  or  a  quick,  darting  forward  motion. 

Biological  Characters.  Products  of  vital  activity.  They  may 
be  ascertained  in  the  same  manner  as  in  the  study  of  micrococci. 
Pigment-production  is  seen  in  cultures  of  the  bacillus  pyocyaneus  or 
bacillus  of  green  pus,  of  which  there  are  several  varieties  producing 
various  shades  of  blue  or  fluorescent  green.  Liquefaction  of  gelatin. 
This  is  produced  by  the  bacillus  authracis  and  the  bacillus  pyocyaneus, 
the  "  comma  "  bacillus  of  cholera  and  many  other  species.  Production 
of  acids.  The  bacillus  coli  communis  produces  lactic  acid.  Fermen- 
tation. The  latter  bacillus  sets  up  fermentation  of  carbohydrates,  as 
of  glucose,  lactose,  and  saccharose.     (See  Plate  II.) 

The  Spirilla.  Morphology.  They  are  seen  in  the  form  of  curved 
rods  or  spiral  filaments.  The  shorter  ones  are  curved,  the  longer  are 
spiral,  like  a  corkscrew.  The  curved  filaments  may  be  short  and  rigid, 
or  long  and  flexible. 

Reproduction.     They  reproduce  by  binary  division  (fission). 

Biological  Characters.  Motility.  They  are  motile;  the  move- 
ment is  rotary,  as  well  as  progressive  in  the  direction  of  the  long  axis 
of  the  filament.  The  presence  of  flagella  is  determined  by  Loffler's 
method  of  staining.  They  are  single  at  the  ends  of  rods,  or  several 
are  seen  at  one  extremity,  or  one  or  more  may  occur  at  both  ends. 
Pigment-production.  Pathogenic  spirilla  do  not  produce  pigment. 
Liquefaction  of  gelatin.  The  spirillum  of  cholera  Asiatica  (comma- 
bacillus)  and  the  spirillum  of  cholera  nostras  (Fiukler  and  Prior) 
both  liquefy  gelatin  in  a  peculiar  manner.      (See  Plate  II.,  Fig.  4,  a.) 

Methods  of  Research.  Having  learned  the  morphological  and 
biological  characters  of  the  various  forms  of  pathogenic  bacteria,  the 
student  is  prepared  to  use  his  knowledge  for  diagnostic  purposes.  I 
have  said  that  methods  of  bacteriological  research  must  be  employed; 
the  following  account  is  to  embrace  the  steps  that  should  be  taken  to 
ascertain  the  presence  of  a  micro-organism  in  the  blood,  the  secretions 
or  excretions,  the  fluids  of  cavities  or  cysts  (exudations,  transudations, 
and  cystic  fluids).  When  there  is  no  distinctive  pathological  fluid,  all 
the  fluids  of  the  body  must  be  examined.      In  other  cases,  the  patho- 


BA  GTEBIOLOGIGAL  I) 1. 1  GNOSIS.  1 55 

logical  discharge  (pus),  or  perhaps  the  diseased  tissue,  must  be  exam- 
ined. We  get  a  clue  to  the  direction  which  the  examination  is  to  take 
from  the  nature  of  the  symptoms.  In  cases  of  pulmonary  disease, 
the  sputum  ;  of  faucial  disease,  the  membrane,  pus,  or  other  secretions 
from  the  fauces  ;  in  intestinal  disease,  the  discharge  from  the  bowels; 
and  in  genito-urinary  disease,  the  urine.  It  must  not  be  forgotten  that 
in  many,  even  highly  fatal  diseases,  the  blood  is  not  invaded  by  micro- 
organisms. Death  is  due  to  the  development  of  toxic  substances. 
Hence,  as  in  cholera  and  diphtheria,  the  presence  of  the  micro-organism 
is  not  sought  for  in  the  blood,  but  in  the  specific  excretion  or  exudation. 

The  method  of  procedure  is  :  1.  Microscopical  examination  of  a 
minute  particle  of  the  stained  and  unstained  blood  or  of  the  morbid 
secretion  or  excretion.  2.  Isolation  of  the  micro-organisms  in  pure 
culture  by  the  plate-method.  3.  Inoculation  of  animals  with  pure 
cultures  of  the  suspicious  organism  or  organisms. 

The  Apparatus.  The  apparatus  necessary  for  the  simplest  bacte- 
riological research  comprises  the  following  :  Sterilizers,  incubators, 
glass  flasks,  covered  dishes,  test-tubes  and  plates,  platinum  needles 
fixed  in  glass  handles,  raw  cotton,  materials  for  culture-media,  micro- 
scope, with  slides  and  cover-glasses,  and,  in  addition  to  lenses  of  lower 
powers,  a  one-twelfth  oil-immersion  lens,  and  finally  the  various  stains 
used. 

Preparation  of  apparatus.  Boil  all  glassware  for  half  an  hour  in  a 
solution  of  common  soda  (2  to  3  per  cent.),  then  scrub  thoroughly, 
rinse  in  warm  solution  of  HC1  (1  per  cent.),  and  then  in  pure  water, 
drain  with  tops  down  ;  plug  tubes  and  flasks  with  raw  cotton,  fitting 
firmly  and  evenly,  so  that  the  cotton  can  hold  the  weight  of  the  test- 
tube  ;  sterilize  in  dry  oven.  The  test-tubes  (plugged)  are  placed  in  a 
rack  for  further  use. 

The  tubes  and  flasks  are  best  filled  with  the  culture-media  through 
a  spherical  funnel  that  can  be  plugged  with  cotton.  Then  they  are  to 
be  sterilized  in  the  steam  sterilizer  as  heretofore  described. 

The  cover-glasses  must  be  thoroughly  cleansed  by  immersion  in 
strong  nitric  acid  for  a  few  hours,  then  rinsed  in  water,  then  in  alcohol 
and  ether.     They  are  then  kept  in  alcohol. 

Sterilization.  It  should  be  understood  that  the  first  requisite  for 
the  prosecution  of  these  studies  is  to  secure  absolute  cleanliness  and  to 
prevent  the  invasion  of  extraneous  micro-organisms.  The  first  step  is 
thorough  sterilization  of  all  appliances  required  for  work,  and  of  all 
the  media,  to  destroy  previously  existing  bacteria. 

The  sterilization  is  best  accomplished  with  steam  where  the  objects 
to  be  sterilized  admit  of  it.  With  dry  heat  a  temperature  of  at  least 
150°  C.  must  be  applied  for  at  least  an  hour,  and,  of  course,  can  only 
be  used  for  glassware  and  metal  instruments.  All  media  (see  page 
159),  whether  solid  or  fluid,  are  sterilized  by  steam.  Media  which 
cannot  withstand  long  exposure  to  the  necessary  heat  are  sterilized  by 
the  intermittent  application  of  steam.  The  reason  that  this  is  effective 
is  that  fully  developed  bacteria  are  destroyed  at  a  much  lower  temper- 
ature and  with  shorter  exposure  than  are  the  spores.  One  application 
kills  the  developed   bacteria,  then  the  material  is  kept  for  a  time  in  an 


156  GENERAL  DIAGNOSIS. 

incubator;  spores  develop  into  bacteria  and  are  easily  killed  by  a  second 
application.  By  repeating  this  process  irom  three  to  five  times  the 
substance  is  effectually  sterilized.  If  the  exposure  is  made  longer,  a 
much  lower  degree  of  heat  may  be  used,  so  that  in  the  case  of  blood- 
serum  it  may  be  sterilized  without  coagulating  the  albumin.  Usually 
an  exposure  of  fifteen  minutes  to  steam  on  each  of  three  successive  days 
is  used  for  stable  media,  and  an  exposure  of  an  hour  on  six  successive 
days  to  a  temperature  of  70°  C.  for  more  delicate  media,  as  blood- 
serum.  In  the  intervals  the  material  must  be  kept  at  a  temperature 
of  25°  to  30°  C  A  single  application  of  steam  under  oue  to  one 
and  one-half  atmosphere  pressure  is  now  often  used. 

The  ordinary  " Arnold  steam  sterilizer"  is  as  good  as  any.  The 
dry  sterilizer  is  merely  a  metal  box  with  copper  bottom  and  ventilating- 
holes.      It  is  well  to  have  an  asbestos  casing. 

Metallic  articles,  as  forceps,  platinum  probes,  etc.,  are  best  sterilized 
in  the  flame  of  a  Bunsen  burner. 

Collection  of  Material.  A  definite  careful  method  must  be 
observed  when  the  pathological  product  is  removed  from  the  patient, 
or  collected  for  investigation  (see  Chapter  V. — Exploratory  Puncture). 
Pus  and  fluids  should  be  placed  in  sterilized  glass  bottles  or  tubes,  care 
having  been  taken  that  instruments  for  the  removal  of  the  fluid  were 
previously  sterilized.  Exposure  to  air  should  be  as  brief  as  possible. 
The  fluids  should  not  be  contaminated  with  blood  or  antiseptic  fluids 
used  for  flushing  or  other  surgical  procedure.  If  an  abscess  is  opened 
or  purulent  peritonitis  cut  down  upon,  for  instance,  tube-inoculations 
can  be  made  at  the  bedside.  The  previously  sterilized  platinum  point 
should  be  kept  before  use  in  a  test-tube,  closed  with  sterilized  cotton. 
It  is  dipped  into  the  pus  before  it  flows  over  the  skin,  and  the  pus 
should  be  free  from  the  blood  of  the  incision.  It  is  at  once  trans- 
ferred to  the  medium  in  the  test-tube.  Sputum  should  be  collected  in  a 
previously  sterilized  bottle,  or  one  thoroughy  cleansed  by  boiling.  The 
bottle  should  have  a  wide  mouth.  Care  must  be  taken  to  secure  sputum 
from  the  lungs,  and  not  the  secretion  from  the  mouth  and  fauces. 
Purulent  portions,  rather  than  mucoid,  are  to  be  sent  for  examination. 
Blood  should  be  examined  at  the  bedside  microscopically,  and  cultures 
made  at  the  same  time.  Cover-slip  preparations  may  be  made  at  the 
bedside  for  future  staining.  Intestinal  discharges  may  be  collected  in 
sterilized  glass  jars  and  examined  as  soon  as  practicable.  It  may  be 
necessary  to  keep  the  discharge  at  the  temperature  of  the  body.  (See 
Faeces — amoeba  dysenterica. ) 

To  secure  blood  for  microscopical  study  the  finger  must  be  thor- 
oughly cleansed  with  alcohol  and  puncture  made  with  a  sterilized  lancet 
or  needle.  After  the  blood  flows  a  few  seconds  it  is  removed  and  the 
cover-slip,  previously  cleansed  in  nitric-acid  solution,  is  gently  pressed 
upon  the  second  overflow.  Another  cover  is  placed  over  the  blood- 
stained surface  of  the  first  slip,  the  two  rubbed  together  and  separated 
by  sliding  them  apart.  Sternberg  prefers  to  spread  the  blood,  which 
was  collected  at  the  edge  of  the  cover  slip,  by  drawing  a  polished  glass 
slide,  held  at  an  acute  angle,  over  the  cover-slip.      In  either  case  this 


BACTERIOLOGICAL  DIAGNOSIS.  157 

thin  film  of  blood  is  allowed  to  dry,  and  can  be  examined  later.    Stern- 
berg mounts  the  blood  on  a  glass  slide  at  once. 

Microscopical  Examination.  The  blood  and  fluids,  stained  and 
unstained,  and  colonies  of  the  preliminary  and  pure  cultures  are  exam- 
ined. The  methods  for  each,  as  to  technique,  are  about  the  same. 
The  cover-slips  that  are  stained  must  be  examined  with  the  oil-immer- 
sion objective,  and  the  diaphragm  of  the  sub-stage  condensing  apparatus 
(Abbe's)  open.  Wheu  the  specimen  is  not  stained  the  diaphragm 
must  be  nearly  closed. 

The  blood  may  be  examined  without  staining.  The  bacillus  of 
anthrax  and  the  spirillum  of  relapsing  fever  may  be  thus  detected. 
Basic  aniline  dyes  are  used  to  stain  the  cover-slip  preparation,  or  the 
method  of  Loffler  or  Gram  is  employed. 

The  secretions  in  general  are  examined  by  the  same  method.  By 
Giinther's  method  the  spirillum  of  relapsing  fever  is  detected  in  the 
blood.  Examination  of  the  blood,  and  the  sputum  for  tubercle  bacilli 
aud  other  micro-organisms,  will  be  described  in  the  section  on  Sputum. 

The  examination  of  the  nasal  and  buccal  secretions  is  described  in 
the  appropriate  chapter.  Gram's  and  Giinther's  methods  are  of  value. 
Search  for  the  bacteria  in  the  alimentary  tract  (see  Vomit  and  Faeces) 
must  be  made  in  accordance  with  the  methods  described  in  those  sec- 
tions and  by  the  methods  of  staining  hereafter  described.  The  urine 
is  studied  by  the  Gram  and  by  the  Fried  lander  method.  The  study  of 
pus  will  be  described  later. 

Examination  of  Colonies.  Just  here  may  be  stated  the  methods 
employed  for  the  study  of  the  morphology  of  the  colonies  secured  by 
plate  and  other  means  of  cultivation.  The  same  process  applies  to  the 
examination  of  pus  aud  pathological  fluids. 

Cover-glass  preparations  are  made  as  follows:  On  the  cover-glass 
place  a  small  drop  of  distilled  water.  With  a  platinum  needle  take 
up  the  smallest  possible  quantity  of  the  colony  to  be  examined,  mix  it 
with  the  drop  and  spread  over  the  surface  of  glass.  Dry  under  cover  or 
by  holding  with  fingers  over  a  flame,  the  layer  of  bacteria  being  away 
from  the  flame.  When  dry  pass  it  with  forceps  three  times  through 
the  gas  or  alcohol  flame  to  "fix"  the  albumin.  It  is  then  ready  for 
staining. 

Methods  of  Staining.  Many  have  been  devised,  but  those  of 
clinical  value  are  the  following: 

1.  Aqueous  solutions  of  basic  anilines. 

2.  Loffler' s  alkaline  methyl-blue. 

3.  Koch-Ehrlich's  aniline  water  solutions. 

4.  Ziehl's  carbol-fitchsin. 

5.  Loffler' s  method  of  staining  flagella. 
0.   Gram's  method. 

7.  Friedlander's  method. 

8.  Giinther's  method. 

1.  Basic  anilines.  Aqueous  solutions  of  the  basic  aniline  colors — 
fuchsin,  gentian-violet,  and  methyl-bliK — are  used  of  such  strength 
that  they  can  be  seen  through  clearly  in  an  ordinary  test-tube.     They 


158  GENERAL  DIAGNOSIS. 

may  be  kept  on  hand  in  bottles  with  pipettes,  or  made  from  concentrated 
alcoholic  solutions  as  needed.  They  are  used  by  simply  dropping  a  few 
drops  on  the  cover-glass  preparation,  which  is  held  with  the  forceps, 
allowing  it  to  remain  about  thirty  seconds,  and  carefully  washing  off 
in  water.  It  is  placed  on  a  slide,  bacteria  down,  and  the  excess  of 
water  removed  with  blotting-paper. 

2.  Loffler's  alkaline  methyl-blue  solution.  Certain  bacteria  take  a 
stain  more  readily  when  an  alkali  has  been  added.  The  formula  is  as 
follows : 

Concentrated  alcoholic  solution  methyl-blue 30  cc. 

Caustic  potash,  1 :  10,000 100" 

It  is  used  in  the  same  way  as  the  simple  solutions. 

3.  Ivoeh-Ehrlich  aniline-water  solutions.  Add  to  100  cc.  of  dis- 
tilled water,  aniline  oil,  drop  by  drop,  thoroughly  shaking  after  each 
drop,  until  it  becomes' opaque.  Then  filter.  Add  10  cc.  absolute 
alcohol  and  11  cc  of  a  concentrated  alcoholic  solution  of  either  fuchsin,, 
methyl-blue,  or  gentian-violet. 

4.  Ziehl's  carbol-fuchsin  solution. 

Distilled  water 100  cc. 

Carbolic  acid 5  gm. 

Alcohol 10  cc. 

luchsin ■ 1  gm. 

The  use  of  these  various  stains  will  be  described  in  the  description 
of  the  different  bacteria. 

5.  Loffler's  solution  for  flagella. 

Tannic  acid,  20  per  cent.        .        .        ...        . 10  cc. 

Cold  saturated  sol.  ferric  phosphate 5-  " 

Saturated  solution  fuchsin 1    " 

A  few  drops  of  this  solution  are  placed  on  the  cover-glass  containing 
the  bacteria  and  very  gently  heated  until  they  begin  to  steam,  and  then 
the  cover-glass  is  washed  oif  in  water.  The  preparation  is  then  stained 
with  aniline  water  fuchsin.  Different  bacteria  require  different  reac- 
tions, and  so  a  lew  drops  of  an  acid  or  alkaline  solution  are  recom- 
mended to  be  added  as  the  case  requires.  As  a  rule,  however,  the 
results  obtained  when  neither  acids  nor  alkalies  are  added  are  just  as 
satisfactory  as  those  following  such  additions. 

6.  Gram's  method  consists  in  staining  with  a  Koch-Ehrlich  solution 
of  gentian-violet  for  twenty  to  thirty  minutes,  and  then  decolorizing  in 

Iodine 1  gm. 

Potassium  iodide 2    " 

Distilled  water 300  cc 

After  remaining  in  this  for  five  minutes  preparations  are  rinsed  in 
alcohol,  and  the  process  repeated  until  the  violet  color  has  disappeared. 

For  Gunther's  and  Friedlander'  s  methods,  see  Sputum. 

To  detect  spores  of  bacilli  double  staining  may  be  employed.  The 
preparation  is  first  stained  in  a  hot  Ziehl-Xeelsen  fuchsin  solution,  then 
decolorized  with  alcohol  containing  from  0.2  to  0  3  per  cent,  hydro- 
chloric acid.  When  stained  again  with  methylene-blue  the  spores 
appear  red,  the  bacilli  blue. 

The  "  hanging  drop."  By  the  examination  of  colonies  in  the  hang- 
ing drop  we  learn  of  the  movement  of  the  micro-organism.      Place  a 


BACTERIOLOGICAL  DIAGNOSIS.  159 

drop  of  physiological  salt  solution  on  a  cover-slip,  and  add  a  tiny  por- 
tion of  colony  on  platinum  wire;  place  the  slip  drop  down,  on  a  glass 
slide,  in  the  centre  of  which  is  a  depression  or  hollow.  Fix  the  slip  by 
applying  a  thin  layer  of  vaseline  around  the  margin  of  the  depression. 
Care  must  be  taken  in  focussing  that  the  lens  does  not  break  the  glass, 
readily  done  because  of  the  transparency.  The  bacteria  are  seen  in 
motion;  on  account  of  the  motion  their  position  is  constantly  altered. 
This  motion  must  not  be  mistaken  for  the  Brownian  movement  of  sus- 
pended particles  which  is  vibratory  from  molecular  tremor. 

Cultivation  of  Micro-organisms.  The  object  is  to  isolate  the 
pathogenic  organism  from  all  other  organisms  and  to  exclude  organisms 
that  may  be  introduced  from  without  by  unclean  instruments  or  other 
means.      Pure  cultures  are  thus  obtained. 

Culture-media.  Experience  has  taught  us  that  various  forms  of 
bacteria  require  different  pabulum,  and  that  various  nutrient  media  are 
required  for  the  isolation  of  different  micro-organisms.  As  to  the  bac- 
teria hereafter  noted,  we  are  familiar  with  the  proper  soil  for  their 
growth.  The  media  used  for  bacteria  of  clinical  importance  are  : 
freshly  steamed  potato,  gelatin,  bouillon,  agar-agar,  milk,  and  blood- 
serum.  They  are  prepared  or  mixed  in  various  ways,  and  other  things 
may  be  added,  as  a  solution  of  litmus,  to  determine  the.  reaction  of  the 
bacterial  products. 

Bouillon.  Lean  beef,  500  gin.,  soaked  in  one  litre  of  water  for 
twenty-four  hours  in  ice-chest;  strain  through  a  coarse  towel  and  press 
until  a  litre  of  fluid  is  obtained.  Add  10  gm.  of  dried  peptone  and 
5  gm.  salt.  Then  neutralize  with  a  normal  solution  (4  per  cent.)  of 
caustic  soda.      Boil  till  albumin  is  coagulated;  filter  and  sterilize. 

Nutrient  Gelatin.  Make  bouillon  as  above  (except  neutralizing)  and 
add  10  to  12  per  cent,  of  gelatin,  and  neutralize  after  dissolving  it  by 
heat.     Filter. 

If  not  perfectly  transparent,  clarify  by  heating  to  60°  to  70°  C,  add 
whites  of  two  eggs  beaten  up  with  50  c.c.  of  water  ;  mix  thoroughly 
and  boil  until  albumin  coagulates  ;  then  filter.  Sterilize  and  keep  in 
flasks  or  tubes. 

Nutrient  Agar.  Prepare  bouillon  complete  ;  add  finely  chopped 
agar,  1  to  1.5  per  cent.  Place  in  a  porcelain-lined  iron  vessel,  mark 
level  of  fluid,  add  250  c.c.  of  water  and  boil  slowly,  with  occasional 
stirring,  for  three  or  four  hours.  Keep  the.  fluid  up  to  the  mark  by 
adding  water.  Take  the  vessel  from  the  fire  and  set  in  cold  water. 
Stir  until  cooled  to  68°  to  70°  C. ;  add  the  whites  of  two  eggs  beaten 
up  in  50  c.c.  of  water.  Mix  carefully  and  boil  for  half  an  hour, 
keeping  the  fluid  up  to  the  level.      Filter. 

Sometimes  5  to  7  per  cent,  of  glycerin  is  added. 

Potatoes.  Select  old  potatoes  ;  scrub  under  water  faucet  with  stiff 
brush  ;  cut  out  eyes  and  defects.  Then  place  in  1  :  1000  HgCL  (or 
twenty  minutes.  Then  place  in  steam  sterilizer  and  steam  forty-five 
minutes.  Leave  them  in  and  steam  fifteen  or  twenty  minutes  each 
day  for  three  days.  Cut  with  knife  sterilized  in  flame  and  lay  with  cut 
surface  upward  in  a  sterilized  covered  dish. 


160  GENERAL  DIAGNOSIS. 

Another  way  of  preparing  potato  is  to  cut  cylinders  with  a  cork 
borer  of  such  size  as  to  fit  loosely  in  a  test-tube.  A  slanting  suriace 
is  then  cut  from  the  junction  of  the  first  and  secoud  thirds  of  the 
cylinder  to  the  diagonally  opposite  edge.  These  are  leit  in  running- 
water  over  night,  then  placed  in  test-tubes  with  a  cotton  plug  and 
steamed  for  forty-five  minutes.  On  the  second  and  third  days  they 
are  steamed  fifteen  to  twenty  minutes. 

Milk.  It  should  be  sterilized  in  steam  sterilizer  by  the  fractional 
method.     It  is  a  good  soil  for  the  tubercle  bacillus.     (Abbott.) 

Blood-serum.  The  original  method  of  preparing  blood-serum,  as 
recommended  by  Koch  (given  iu  the  text-books  on  Bacteriology),  has, 
in  this  country  at  least,  almost  eutirely  given  place  to  the  method  of 
Councilman  and  Mallory,  the  popularity  of  which  is  due  to  the  follow- 
ing advantages:  By  it  the  serum  is  more  quickly  and  easily  prepared; 
rigid  precautions  against  contamination  during  collection  of  serum  are 
not  necessary,  and  the  resulting  medium,  while  not  transparent  or  even 
translucent  (points  aimed  at  in  the  original  method),  fully  meets  all  the 
requirements. 

The  special  points  in  the  method  are  :  the  serum  is  decanted  into 
test-tubes  as  soon  as  obtained;  it  is  then  firmly  coagulated  in  a  slanting 
position  in  the  dry-air  sterilizer  at  from  80°  to  90°  C. ;  it  is  then  ster- 
ilized in  the  steam  sterilizer  at  100°  C.  on  three  successive  day.-,  as  in 
the  case  of  other  culture-media.  It  may  then  be  protected"  against 
evaporation  by  sterilized  rubber  caps  or  sterilized  corks,  and  set  aside 
until  needed. 

Unless  the  coagulation  in  the  dry  sterilizer  be  complete,  the  surface 
of  the  serum  will  be  found  to  be  lacerated  by  bubbles  and  cavities  after 
it  has  been  subjected  to  the  steam  sterilization.  A  similar  formation  of 
cavities  over  the  surface  of  the  serum  will  occur  if  the  temperature  of 
the  hot-air  sterilizer,  in  which  it  is  solidified,  is  allowed  to  get  above 
DO0  C,  or  if  it  be  elevated  to  this  point  too  quickly. 

It  is  of  no  special  advantage  to  have  the  serum  clear,  as  the  admix- 
ture of  blood-coloring  matter  does  n  it  affect  its  nutritive  properties. 

Loffler's  blood-serum  mixture. 

Neutral  meat  infusion  bouillon  (see  Bouillon) 1  part. 

Grape-sugar 1  per  cent. 

Blood-serum 3  parts. 

Tube-  axd  Plate-cultures.  The  plate  method  was  introduced 
by  Koch  for  the  purpose  of  isolating  individual  species  of  bacteria  from 
mixtures.  It  may  be  practised  either  with  gelatin  or  agar-agar.  Three 
tubes  previously  filled  with  the  culture-media  are  liquefied  by  warming 
in  a  water-bath,  then  cooled  to  the  lowest  point  at  which  the  medium 
remains  fluid.  One  of  the  tubes  is  then  held  in  the  left  hand.  A 
sterilized  looped  platinum  Avire  inserted  in  a  glass  handle  is  taken  in 
the  other  hand,  passed  through  a  flame,,  and  cooled  for  a  few  seconds. 
With  this  a  bit  of  the  material  to  be  examined  is  taken  up,  the  cotton 
plug  is  removed  from  the  tube  with  the  free  fingers,  and  the  wire  inserted 
into  the  medium.  By  rolling  the  tube  it  is  thoroughly  mixed.  Then 
a  second  tube  is  inoculated  with  three  loopfuls  from  the  first,  and  a 
third  with  three  loopfuls  from  the  second.     Plates  have  been  previously 


BACTERIOLOGICAL  DIAGNOSIS.  161 

sterilized  and  placed  in  covered  dishes  also  carefully  sterilized.  The 
plates  are  levelled  and  the  contents  of  tubes  poured  upon  their  surface 
Then  they  are  cooled  over  ice-water  until  the  medium  becomes  solid, 
when  they  are  placed  in  a  proper  temperature  for  development.  In 
this  way  the  bacteria  are  sufficiently  diluted  to  form  distinct  colonies 
from  which  pure  cultures  may  be  obtained. 

A  convenient  modification  of  the  method  is  the  use  of  Petri's  plates, 
which  are  flat,  round  dishes  with  covers,  the  bottom  of  the  dish  serving 
as  the  plate. 

Another  modification  (Esmarch's  tubes)  is  the  use  of  tubes  with  a 
small  quantity  (5  c.c.)  of  the  medium.  By  rolling  the  tube  in  the 
fiugers  the  sides  are  coated  with  the  media.  They  are  then  rolled  on 
ice,  so  that  the  medium  solidifies  iu  a  thin  layer  about  its  walls. 

Smear-  and  Stab-cultures.  "When  the  bacteria  have  been  iso- 
lated by  one  of  these  methods  pure  smear-  or  stab-cultures  must  be 
made  from  them.  A  tube  of  the  proper  culture-medium  is  taken  in 
the  left  hand,  a  bit  of  a  pure  colony  taken  up  on  a  sterilized  straight 
platinum  needle,  the  cotton  plug  removed  as  above,  and  the  needle 
thrust  straight  into  the  medium  for  a  stab-culture,  or  rubbed  over  a 
slanting  surface  of  media  for  a  smear-culture.  The  plug  is  immedi- 
ately inserted  and  the  tubes  transferred  to  the  incubator. 

When  pure  cultures  have  been  obtained  the  species  are  recognized 
by  their  mode  of  growth  and  behavior  in  different  culture-media,  the 
reaction  produced  by  their  growth,  and  their  appearance  under  the 
microscope  when  stained  and  unstained. 

When  nutrient  media  are  inoculated  they  must  be  kept  at  a  favor- 
able temperature.  This  will  be  detailed  when  each  micro-organism  is 
discussed,  as  a  number  of  pathogenic  bacteria  require  a  definite  and 
continuous  temperature. 

The  primary  inoculation  will  often  yield  numerous  colonies,  the 
nature  of  the  bacteria  comprising  which  must  be  determined  by  their 
morphology  and  biological  characteristics.  It  is  frequently  necessary 
to  repeat  the  process  of  plating  with  several  of  the  colonies  obtained 
on  the  original  plates.  Otherwise  one  cannot  always  be  certain  that 
the  organism  for  which  he  is  seeking  has  been  isolated  in  pure  culture. 

Inoculation  of  Animals.  Another  method  of  determining  the 
pathogenic  character  of  morbid  material,  as  sputum,  pus,  or  exudation, 
is  by  inoculating  animals  with  a  pure  culture.  This  is  done  either  by 
feeding,  or  injection,  as  subcutaneous  or  intravenous,  into  the  peritoneal 
or  pleural  cavity,  aud,  in  rare  instances,  into  the  anterior  chamber  of 
the  eye,  or  into  the  cranial  cavity. 

As  animals  are  subject  to  only  a  few  of  the  microbic  diseases  of 
man,  many  experiments  must  often  be  made  before  a  susceptible  ani- 
mal is  found,  and  no  conclusions  can  be  reached  as  to  the  pathological 
power  of  a  micro-organism  until  this  point  has  been  determined.  The 
clinical  course  of  the  artificial  disease  must  be  observed  to  fulfil  the 
diagnosis,  and  the  difficulty  of  reproducing  faithfully  in  animals  the 
clinical  manifestations  seen  in  man  is  often  one  of  the  gravest  obstacles 
to  this  method  of  diagnosis. 

11 


162  GENERAL  DIAGNOSIS. 

Examination  of  the  animal  is  made  as  soon  as  possible  after  death. 
The  autopsy  is  made  with  antispetic  precautions.  After  the  skin 
is  removed  only  sterilized  instruments  are  to  be  used.  The  macro- 
scopical  appearances  aud  the  mode  and  progress  of  infection  are  noted 
for  the  purpose  of  aiding  in  the  diagnosis.  When  the  organs  are 
exposed,  material  for  culture  is  first  obtained  by  inserting  a  platinum 
needle  through  a  small  puncture  in  the  capsule.  Afterward  cover- 
glasses  may  be  prepared  for  immediate  examination.  Blood  is  taken 
from  oue  of  the  cavities  of  the  heart.  Alter  the  autopsy  all  remains 
are  to  be  burned,  and  all  instruments  carefully  sterilized. 

Special  Bacteriological  Diagnosis.  In  the  preceding  section  the 
general  methods  were  described  by  which  the  micro-organisms  were 
searched  for.  As  they  are  found  in  different  fluids  or  secretions  ol  the 
body,  a  discussion  of  the  individual  forms  the  detection  of  which 
furnishes  an  absolute  diagnosis  will  be  considered  in  different  sections 
which  treat  of  the  special  diseases,  or  the  special  fluid  in  which  the 
organism  is  most  frequently  found.  In  the  subsequent  chapter  the 
method  of  examining  pus  will  be  detailed.  In  that  section  will  be 
found  an  account  of  the  pyogenic  bacteria  (morphology  aud  bacterio- 
logical characteristics),  staphylococcus  and  streptococcus.  The  bacillus 
of  syphilis,  the  gonococcus,  the  fungus  of  actinomycosis,  the  bacillus 
of  glanders,  of  anthrax,  of  leprosy,  aud  of  tetanus,  will  be  given. 
An  account  of  the  micro-orgauisms  of  pneumonia  aud  that  of  tubercu- 
losis will  be  found  iu  the  section  ou  sputum,  of  diphtheria  in  the  sec- 
tion on  the  pharynx,  of  cholera  in  the  section  on  intestiual  diseases 
(fseces),  and  of  typhoid  fever  in  its  appropriate  section.  In  the  section 
on  diseases  of  the  blood,  and  in  the  special  articles  the  spirillum  of 
relapsing  fever  and  the  protozoa  of  malaria  will  be  discussed. 

The  following  points  must  be  investigated  in  order  to  determine  the 
specific  nature  of  the  micro-organism  which  is  supposed  to  be  the  pro- 
ductive agency  of  the  disease  in  question,  viz. :  The  form — micrococci, 
bacilli,  spirilla,  polymorphous;  relation  to  oxygen — aerobic,  facultative 
anaerobic,  strict  anaerobic;  growth  in  nutrient  gelatin — liquefy,  do  not 
liquefy,  do  not  grow  at  "  room,  temperature  ;"  growth  on  potato; 
growth  on  milk — coagulate  milk,  do  not  coagulate,  etc. ;  color  of  growth 
— chromogeuic,  non-chromogenic;  spore-formation ;  movement;  patho- 
genic power. 

jStote.  For  further  information  concerning  technique  the  student  must  refer  to  the  work  of 
Ahbott  on  the  "  Principles  of  Bacteriology  "  and  to  Sternberg's  "  Manual  of  Bacteriology  "  for  an 
exhaustive  account  of  the  technique,  and  the  morphological  aud  bacteriological  characteristics  of 
all  bacteria,  pathogenic  and  non-pathogenic.  The  text-books  of  Hut-ppe,  "  Die  Methoden  der  Bak- 
terein-Forschung,"  1886  ;  Baumgarten,  "  Lehrbuch  der  pathologischen  Mykologie,"  K90  ;  Fluegge, 
"  Die  Micro-organismen,"  1886 ;  and  Cornil  and  Babes,  "  Les  Bacteries,"  i890,  are  profitable  for  the 
further  prosecution  of  studies. 


CHAPTER    V. 

THE  EXAMINATION  OF  EXUDATIONS,  TRANSUDATIONS, 
AND  CYSTIC   FLUIDS. 

Exploratory  puncture  or  aspiration  for  diagnosis :  Instruments.  Preparation  of 
instruments.  Preparation  of  skin.  Point  of  puncture. — Exudations  (Pus. 
Sero  pus  Gangrenous  debris.  Blood.  Serum.  Chyle) :  Pus.  Blood-corpuscles. 
Bacteria.  Protozoa.  Vermes.  Crystals. — Chemical  examination  :  Sero-purulent 
exudations.  Putrid  exudations.  Hemorrhagic  exudations.  Serous  exudations. 
Chylous  exudations.  Pleural  effusions.  Transudations. — The  contents  of  cysts  : 
Hydatid,  ovarian,  renal,  pancreatic. 

Exploratory  Puncture  or  Aspiration  for  Diagnosis.  The  pres- 
ence or  absence  of  fluids  in  the  natural  cavities  of  the  body,  as  the  per- 
icardium, the  pleura,  or  the  abdomen,  or  in  the  gall-bladder,  must 
frequently  be  ascertained  by  means  of  puncture  or  aspiration.  The 
fluid  is  secured  for  examination  in  the  same  way  at  the  same  time. 
The  fluid  of  tumors  or  cysts  is  likewise  withdrawn  to  complete  a  diag- 
nosis by  determining  its  chemical,  microscopical,  or  bacteriological 
character.  Certain  rules  of  procedure  are  necessary,  and,  as  they  are 
common  to  the  method  in  whatsoever  situation  employed,  may  be  con- 
sidered in  this  section. 

The  Instruments.  If  it  is  the  desire  of  the  observer  to  determine  the 
presence  of  fluid,  an  ordinary  grooved  needle  may  be  used..  If,  how- 
ever, fluid  is  to  be  obtained  for  examination,  a  syringe  or  aspirator 
must  be  used.  An  ordinary  hypodermatic  syringe,  or  the  syringe  of 
Pravaz,  may  be  used  if  the  needles  are  long  enough.  A  special  aspi- 
rator made  for  diagnosis  by  instrument-makers  is  the  best.  The 
needles  are  sufficiently  long,  the  barrel  large  enough  to  hold  sufficient 
fluid  for  any  method  of  examination.  If  the  diagnosis  is  to  be  fol- 
lowed by  treatment  by  aspiration,  the  apparatus  of  Dieulafoy,  or  any 
equally  perfect  apparatus,  may  be  used  at  once. 

Preparation  of  Instruments.  The  instruments  should  be  sterilized  in 
a  steam  sterilizer,  or  boiled.  This  does  not  apply  to  the  needles  alone, 
but  every  portion  of  the  instrument  should  be  cleansed,  because,  for 
instance,  the  contents  of  the  barrel  of  the  syringe  pass  through  the 
needle.  After  sterilization  they  should  be  carried  to  the  patient  in  ster- 
ilized test-tubes  plugged  with  cotton- wool.  When  not  in  use  the  needles 
should  be  kept  in  absolute  alcohol,  and  the  syringe  in  carbolic  acid 
solution,  1  :  20.  Before  using,  the  carbolic  acid  should  be  washed  from 
the  syringe  and  needle  with  boiling  water;  they  are  then  to  be  sterilized 
as  described.  Unless  the  carbolic  acid  is  removed  from  the  syringe  its 
presence  may  serve  as  an  antiseptic  or  disinfectant,  and  thus  interfere 
with  the  culture-tests  to  which  the  material  drawn  is  to  be  subjected. 


164  GENERAL  DIAGNOSIS. 

Preparation  of  Skin.  The  skin  should  first  be  cleansed  with  soap 
and  water,  then  with  alcohol,  then  with  a  solution  of  carbolic  acid, 
1  :  20,  or  of  the  bichloride  of  mercury,  1  :  1000.  After  thorough 
cleansing  the  parts  should  be  kept  covered  with  a  towel  soaked  in 
bichloride  solution  until  the  time  of  operation.  At  the  time  of  punc- 
ture the  surface  should  be  made  anaesthetic  by  ethylene  chloride,  the 
rhigolene  spray,  by  ice  and  salt,  or,  in  adults,  by  the  Schleich  method 
of  subcutaneous  anaesthesia.  Care  must  be  taken,  if  the  patient  is  aged 
or  poorly  nourished,  or  the  skin  cedeniatous,  not  to  freeze  the  skin  too 
much,  on  account  of  the  danger  of  local  gangrene. 

The  Point  of  Puncture.  The  points  selected  for  aspiration  depend 
upon  the  cavity  to  be  explored,  or  the  situation  of  the  cyst. 

The  Pleura.  To  withdraw  the  fluid  within  the  pleura  it  is  best 
to  select  a  point  for'  aspiration  in  one  of  the  lower  interspaces  of  the 
chest,  because  the  fluid  is  more  likely  to  accumulate  in  this  position 
and  because  complete  aspiration  can  there  be  performed  if  necessary. 
The  sixth  or  seventh  interspace  in  the  anterior  axillary  line,  or  the 
eighth  or  ninth  interspace  m  the  posterior  axillary  or  scapular  line, 
may  be  selected.  On  the  right  side  the  upper  interspace  of  the  two 
should  be  chosen  on  account  of  the  position  of  the  liver.  If  the  con- 
tents tend  to  point  or  break  out  at  any  particular  spot  on  the  surface  of 
the  chest,  the  puncture  may  be  made  in  this  area.  In  suspected  locu- 
lated  empyema  or  effusions  the  point  of  puncture  should  be  at  the  site 
of  greatest  dulness  and  least  fremitus. 

The  Pericardium.  For  aspiration  of  the  pericardium  three  points  of 
election  have  been  recommended  :  first,  the  usual  position  of  the  apex- 
beat,  in  the  fifth  interspace,  inside  of  the  mid-clavicular  hue  ;  second, 
the  space  between  the  ensiform  cartilage  and  the  left  seventh  cartilage, 
the  point  advised  by  Roberts ;  third,  Rotch  has  tapped  the  fifth  right 
interspace  a  number  of  times  on  the  cadaver,  and  thinks  that  this  situ- 
ation is  a  proper  one  on  the  living  subject.  The  writer  has  aspirated 
the  pericardium  in  several  instances  inside  of  the  normal  position  of 
the  apex.  Care  must  be  taken  to  insert  the  needle  slowly  and  with 
the  point  directed  downward  and  toward  the  left  axilla  when  this  posi- 
tion is  selected. 

The  Abdomen.  It  should  be  remembered  that  no  attempts  at 
puncturing  the  abdomen  should  be  made  if  pus  is  suspected,  unless 
preparations  have  been  made  to  perform  laparotomy  at  once.  Indeed, 
this  exploratory  operation  is  performed  with  so  little  detriment  to  the 
patient  by  modern  surgeons  that,  on  the  whole,  it  should  be  advocated 
instead  of  puncture.  There  are  times,  however,  when  the  latter  must 
be  resorted  to.  The  writer  has  performed  it  in  a  number  of  instances 
— always  refusing  to  do  so  in  cases  in  which  pus  was  probably  present  in 
the  peritoneal  cavity,  or  in  tumors,  or  in  organs  the  seat  of  suppuration 
— without  any  danger  having  ever  arisen.  Explorations  of  this  char- 
acter are  probably  more  feasible  in  connection  with  diseases  of  the  liver. 
It  does  not  appear  to  be  harmful  to  insert  needles  into  that  organ,  and 
valuable  information  is  often  gained  thereby. 

In  aspiration  of  the  abdomen,  to  determine  the  character  of  peritoneal 
contents,  the  median  line  should  be  selected  for  the  puncture.      The 


EXUDATIONS,  TRANSUDATIONS,  AND  CYSTIC  FLUIDS.     165 

bladder  must  be  emptied  and  a  point  midway  between  the  umbilicus 
and  pubes  selected. 

The  Vertebral  Canal.  Proposed  by  Quincke,  the  procedure  has 
been  carried  out  by  many  cliniciaus  and  has  proved  to  be  a  means  of 
corroborating  and  even  establishing  a  diagnosis.  Cerebral  lesions  are 
diagnosed  and  intracranial  pressure  relieved  because  of  the  continuity 
of  the  spaces  in  the  brain  and  the  spinal  canal.  The  puncture  is  made 
by  the  needle  of  a  large  hypodermic  syringe  which  may  then  be  used 
to  withdraw  the  fluid,  or  the  syringe  itself  may  be  removed  and  the 
fluid  allowed  to  ooze  through  the  needle  drop  by  drop.  The  point 
selected  for  puncture  is  midway  between  the  third  and  fourth  or 
fourth  and  fifth  lumbar  vertebrae,  below  the  spinous  process,  a  little 
to  one  side  of  the  median  line.  The  fluid  is  examined  chemically, 
bacteriological ly,  and  microscopically.  Sugar  has  been  found  in  brain- 
tumor  and  not  in  meningitis;  albumin  is  said  to  be  less  in  the  former 
than  in  the  latter.  In  tuberculous  meningitis  the  fluid  is  clear  and 
limpid  ;  in  other  forms  cloudy  and  turbid.  Pus  has  been  withdrawn 
in  leptomeningitis.  The  respective  affection  is  distinguished  by  the 
results  of  bacteriological  examination.  Blood  may  be  found  in 
hemorrhage  into  the  lateral  ventricles. 

Cysts  or  tumors  with  fluid  contents  should  be  punctured  over  the 
point  which  presents  externally,  at  which  place  it  is  evidently  in  closer 
proximity  to  the  external  wall. 

The  spleen  has  been  punctured  for  therapeutic  and  diagnostic  pur- 
poses. If  the  organ  is  hard,  as  in  chronic,  malaria,  it  may  be  done 
without  danger  ;  but  if  it  is  enlarged  and  soft,  as  in  infectious  diseases, 
such  as  typhoid  fever,  it  is  hardly  justifiable  to  puncture  it,  because  of 
the  danger  of  subsequent  rupture.  Risks  attend  the  puncture  of  other 
organs,  as  the  kidney.  The  writer  has  seen  a  serious  hemorrhage 
follow  such  puncture,  and,  of  course,  septic  inflammation  may  arise. 
Exploratory  operation  is  more  suitable  for  determining  its  condition. 

The  Examination  of  Fluids  and  Discharges.  While  the  fluids 
to  be  examined  can  be  obtained  by  the  above-mentioned  method,  it 
sometimes  happens  that  they  are  discharged  spontaneously,  as  in  the 
case  of  an  empyema, 

The  following  general  methods  apply  to  the  examination,  in  what- 
ever way  material  is  obtained.  When  derived  from  the  natural  cavities 
they  are  known  as  exudations  or  transudations.  Fluids  are  also  obtained 
from  cysts,  but  do  not  require  different  methods  of  examination. 

The  naked-eye  appearances  are  first  noted;  then  microscopical  exam- 
ination with  and  without  staining  is  resorted  to.  Chemical  examina- 
tion is  also  required.  Often  culture-preparations  and  inoculations  must 
be  resorted  to,  as  in  the  case  of  pus  or  of  serous  exudation. 

The  Exudations.  They  may  be  composed  of  pus,  sero-pus,  gan- 
grenous debris,  blood,  or  pure  scrum  or  chyle.  When  pus,  sero-pus,  or 
putrid  fluid  is  withdrawn,  it  implies  absolutely  an  inflammatory  origin. 
Blood  and  scrum  may  be  associated  with  inflammation,  simple  or  infec- 
tious ;  but  may  also  point  to  impediments  in  the  general  or  lymphatic 


166  GENERAL  DIAGNOSIS. 

circulation.  Blood  or  bloody  serum  is  thought  to  be  of  tuberculous  or 
cancerous  origin.  Its  absence  does  not  imply  the  absence  of  either 
disease.  A  chylous  exudation  is  usually  due  to  obstruction  of  the 
lymph-channels. 

Purulent  Exudations.  Pus  ranges  in  color  from  gray  to  greenish- 
yellow.  It  is  turbid,  of  high  specific  gravity,  and  alkaline.  It 
varies  in  consistence.  When  standing  after  removal  it  separates  into 
two  layers  ;  the  upper  layer  is  light  yellow  and  transparent,  and  the 
lower  opaque.  Pus  may  be  mixed  with  blood,  and  is  then  reddish- 
brown.  (See  Abscess  of  the  Liver. )  When  it  has  undergone  decom- 
position it  is  thin,  green,  or  brownish-red,  of  a  penetrating  odor. 

Microscopical  Examinations  :  White  Corpuscles.  If  the  specimen  is 
fresh,  the  cells  exhibit  the  movements  that  are  common  in  leucocytes. 
If  a  solution  of  iodine  and  iodide  of  potassium  is  added  to  them,  they 
change  to  mahogany  color.  If  the  pus  is  old  and  the  cells  are  dead, 
they  are  shrunken  and  granular.  Enormous  giant-cells  and  cells  loaded 
with  fat  are  seen  in  pus. 

Red  Corpuscles.  In  fresh  pus  red  corpuscles  are  also  seen  along 
with  blood-pigment  or  hsematoidin-crystals. 

In  addition  to  the  corpuscles  free  fat-globules  and  -particles  are  seen. 
Epithelium  is  rarely  seeu.  In  the  pus  from  the  pleural  cavity,  if  can- 
cer is  present,  the  vacuolated  epithelial  and  endothelial  cells  sometimes 
seen  in  cancer  may  be  observed. 

Bacteria.  Micro-organisms  are  always  detected  with  the  aid  of 
staining-methods.  The  micro-organisms  are  usually  the  determining 
cause  of  the  suppuration.  Suppuration,  however,  may  be  caused  by 
chemical  substances,  although  this  is  at  least  of  rare  clinical  occurrence. 
Of  the  various  fungi  found  the  micrococci  and  bacilli  are  the  most  com- 
mon. Both  pathogenic  and  non-pathogenic  varieties  are  observed. 
The  most  common  are  the  staphylococcus  pyogenes  aureus  and  strepto- 
coccus pyogenes.  In  the  pus  of  empyema  the  micrococcus  lanceolatus, 
or  pneumococcus,  is  frequently  found,  particularly  in  the  empyema  that 
occurs  secondarily  to  pneumonia.  The  bacillus  coli  communis  is  found 
in  abscesses  about  the  peritoneum  and  in  purulent  peritonitis,  the  amoeba 
dysenterica  in  abscess  of  the  liver  and  secondary  abscess  of  the  pleura 
and  lung.  It  was  found  in  an  abscess  of  the  jaw  by  Flexner.  The 
micrococci  are  detected  by  the  staining-methods.  Gram's  method  is 
the  most  satisfactory. 

After  a  cover-glass  has  been  prepared  and  placed  in  Koch-Ehrlich' s 
solution  of  gentian- violet  and  aniline  water,  it  is  put  into  a  solution  of 
iodine  and  iodide  of  potassium  for  two  or  three  minutes.  A  dull  red- 
brown  color  is  produced.  It  is  then  rinsed  in  absolute  alcohol  for  some 
time.  The  micro-orgauisms  are  stained  dark  blue.  The  iodide  of 
potassium  solution  is:  Iodine,  1  part;  iodide  of  potassium,  2  parts; 
distilled  water,  300  parts.  By  this  meihod  the  various  forms  of  micro- 
organisms just  indicated  are  readily  brought  out. 

The  Pyogenic  Bacteria.  1.  Staphylococcus  Pyogenes 
Aureus.  This  micro-organism  is  found  in  acute  abscesses  and  boils, 
sometimes  also  in  infectious  osteomyelitis  and  ulcerative  endocarditis. 


Fig.  i. 


PLATE    I. 
FIG.  2. 


Streptococcus— Erysipelas.      Streptococcus  Septicus. 

fig.  4-  Fig.  5. 


Fig.  3. 


Staphylococcus. 
FIG.  6. 


I 


Diphtheria-bacilli. 


Typhoid  Bacilli.  Tuberculosis-bacilli. 


EXUDATIONS,  TRANSUDATIONS,  AND  CYSTIC  FLUIDS.     167 

Iu  addition  to  other  portals  it  may  enter  the  tissues  through  abrasions 
or  the  hair-follicles. 

Morphology.  In  cover-glass  preparations  they  appear  as  small  round 
bodies  scattered  among  the  pus- cells,  rarely  within  them,  single,  in  pairs 
or  clusters.    They  stain  readily  with  the  basic  aniline  dyes.    (Fig.  17.) 

Biological  properties.  It  is  aerobic,  facultative  anaerobic,  grows  in 
milk,  meat-infusions,  gelatin,  or  agar  at  18°  C.  Death-point  is  56° 
to  58°  C.  after  ten  minutes'  exposure.  Growth.  Make  plate-cultures 
on  agar-agar.  After  twenty-four  hours  in  the  incubator  the  plate  will 
be  studded  with  yellow  or  orange-colored  colonies,  round,  moist,  and 
glistening.  In  a  gelatin  stab-culture  liquefaction  occurs  in  thirty-six 
to  forty-eight  hours  along  the  puncture,  forming  a  funnel.  The  whole 
mass  gradually  liquefies.  At  the  bottom  of  the  funnel  the  microbes 
collect  as  an  orange-colored  mass.  On  potato  it  grows  as  a  brilliant, 
orange-colored,  somewhat  lobulated  layer.  The  growth  gives  off  an 
odor  of  sour  paste.     (See  Plate  I.,  Fig.  3,  and  Plate  II.,  Fig.  2,  b.) 

Fig.  17. 


Pus  with  staphylococcus.    X  800.    (FlxJgge.) 

2.  Staphylococcus  Pyogenes  Albus.  It  is  also  found  in  acute 
abscesses,  but  less  often  than  the  "  aureus,"  and  is  less  virulent. 

It  is  morphologically  identical  with  the  "  aureus,"  but  develops  no 
pigment.  The  surface-cultures  are  milk-white,  and  the  mass  at  the 
bottom  of  the  liquefying  gelatin  is  white. 

3.  Staphylococcus  Epidermidis  Albus  (Welch)  closely  simu- 
lates the  staphylococcus  pyogenes  albus.  It  is  the  most  common  micro- 
organism on  the  surface  of  the  body,  and  is  often  present  in  parts  of 
the  epidermis  too  deep  for  disinfection  save  by  heat.  It  is  supposed  to 
be  the  usual  cause  of  "  stitch-abscess." 

4.  Streptococcus  Pyogenes.  It  is  found  in  acute  abscesses,  ery- 
sipelas, otitis  media,  puerperal  metritis,  ulcerative  endocarditis,  pseudo- 
diphtheria,  scarlatinal  angina,  and  most  purulent  inflammations  of  a 
phlegmonous  character.  It  is  the  organism  most  commonly  found  in 
inflammations  having  a  spreading  tendency. 

Morphology.  Cover-glass  preparations  show  spherical  cocci  of  vary- 
ing sizes,  which  form  chains  of  four  to  twenty  elements,  the  chains 
often  forming  tangled  masses.  It  is  stained  by  the  basic  anilines  or 
by  Gram's  method.     (See  Fig.  18.) 


168  GENERAL  DIAGNOSIS. 

Biological  properties.  Grows  in  most  media  at  a  temperature  of  16° 
to  37°  C.  (best  30°  to  37°),  but  not  on  potato.  It  is  facultative  anae- 
robic, and  does  not  liquefy  gelatin.  On  plates  it  forms  a  flat,  trans- 
parent disk  of  about  one-half  millimetre  diameter.  In  stab-cultures 
it  grows  all  along  the  puncture  and  forms  a  white  opaque  granular 
column.  The  death-point  is  52°  to  54°,  ten  minutes'  exposure.  (See 
Plate  I.,  Figs.  1  and  2.) 

Fig.  18. 


Streptococcus  pyogenes  in  pus.    XSOO.    (Flugge.) 

Inoculated,  it  causes  erysipelatous  or  phlegmonous  inflammation. 

5.  The  Tubercle  Bacillus.  This  is  seen  at  times  in  pus  removed 
from  phthisical  cavities,  and  the  pus  of  abscesses,  particularly  about 
glands.  It  may  be  detected  by  methods  of  staining  adopted  in  the 
examination  of  the  sputum.  Pus  may  be  of  tubercular  origin,  and 
the  micro-organisms  may  not  be  detected  by  the  usual  microscopical 
methods.  Its  absence,  therefore,  does  not  imply  the  absence  of  tubercle. 
Culture -methods  and  inoculation  should  be  resorted  to,  particularly  the 
latter. 

6.  Bacillus  of  Syphilis.  The  pus  under  these  circumstances  is 
usually  derived  from  ulcers  or  inflammations,  or  from  secretions  about 
the  vulva  or  prepuce.  The  actual  relationship  to  syphilis  has  not  been 
demonstrated. 

Lustgarten's  method  is  as  follows:  After  immersion  for  twenty-four 
hours  at  the  ordinary  temperature  in  the  gentian-violet  fluid  of  Koch- 
Ehrlich,  the  cover-glass  preparation  is  removed  and  washed  for  a  few 
moments  with  absolute  alcohol.  It  is.  theu  placed  for  ten  seconds  in  a 
1  per  cent,  or  2  per  cent,  solution  of  permanganate  of  potash;  a  watery 
solution  of  pure  sulphurous  acid  is  then  poured  over  it,  after  which  it 
is  washed  in  water.  If  the  preparation  still  shows  its  color,  it  must  be 
re-immersed  for  a  few  seconds  in  the  potash  solution  and  then  in  the 
sulphurous  acid,  and  again  washed  with  water. 

7.  Actinomyces.  Israel,  Ponfick,  and  Bostrom  have  given  us  the 
greatest  amount  of  information  in  regard  to  this  pai'asite.  It  was  dis- 
covered in  1845,  in  human  beings,  by  B.  v.  Langenbeck,  and  in  1877, 
in  cattle,  by  Bollinger. 

It  is  usually  associated  with  chronic  inflammation  and  the  production 
of  pus.  The  pus  is  peculiar.  It  is  thin  and  viscid.  Small  nodules 
of  gray  or  yellow  color  the  size  of  a  poppy- seed  can  be  seen  by  the 
naked  eye  when  it  is  spread  out  on  a  glass.  With  a  low  power  these 
particles  are  aggregations  of  spherules,  which  with  a  higher  power  are 


PLATE    II. 


FIG.   i. 


FIG.  2. 


3M-& 


e  ■•■ 


v-  .... 

8    & 


A.  Tubercle-bacilli.     B.  Pneumococcus.     A.  Anthrax.     B.  Streptococcus  and  Staphylococcus. 
FIG.  3.  FIG.  4. 


A.  Comma-bacillus.     B.  Gonococcus. 
FIG.  5. 


A.  Recurrent  Spirilla.     B.  Leprosy. 
FIG.  6. 


A.  Normal  Blood.     B.  Normal  Blood. 


A.  Leukaemia.     B.  Eberth's  Bacillus. 


EXUDATIONS,  TRANSUDATIONS,  AXD  CYSTIC  FLUIDS.     169 

seen  to  be  arrano-ed  in  masses  radiating  from  a  common  centre.  Each 
separate  spherule  is  pear-shaped.  They  have  high  refractive  power. 
In  the  centre  of  the  masses  a  network  of  fibres  is  seen.  If  the  mass 
be  broken  up,  numerous  club-shaped  forms  in  the  periphery  are  seen, 
while  at  the  centre  a  sort  of  detritus  alone  is  observed.  The  micro- 
organism belongs  to  the  class  of  fission-fungi,  and  the  club-shaped 
bodies  are  the  degenerated  forms.      (See  Fig.  19.) 


Fig.  19. 


Actinomyces. 


Gram's  method  of  staining  brings  out  the  threads  of  the  network 
most  distinctly.  The  centre  is  made  up  of  a  network  of  minute  spher- 
ical organisms,  with  converging  constituent  threads.  The  whole  is 
surrounded  by  a  delicate  envelope.  The  pear-shaped  bodies  may  be 
defined  by  Weigert's  process.  Make  a  solution  of  20  c.c.  of  absolute 
alcohol,  5  c.c.  of  concentrated  acetic  acid,  40  c.c.  of  distilled  water,  and 
sufficient  French  extract  of  litmus  to  color  it  ruby-red  after  repeated 
filtering.  In  this  solution  the  cover-glass  preparations  are  allowed  to 
remain  for  an  hour,  and  then  rinsed  with  alcohol  rapidly  and  placed 
in  a  2  per  cent,  gentian-violet  solution  for  three  minutes.  The  fluid 
should  be  boiled  before  use,  and  filtered  after  cooling.  The  fungous 
threads  are  stained  a  ruby-red,  while  the  central  mass  of  actinomyces 
is  colorless. 

Simple  microscopical  examination  is  usually  sufficient  to  determine 
the  nature  of  the  fungus.  The  recognition  is  more  positive  if  we  bear 
in  mind  the  peculiar  character  of  the  pus  in  which  the  nodules  and  the 
club-shaped  forms  are  seen.  Pure  cultures  have  been  obtained  resem- 
bling macroscopically  the  cultivation  of  the  tubercle  bacillus. 

8.  The  Bacillus  of  Glanders.  The  pus  is  usually  discharged 
from  the  nasal  passages.  It  is  detected  in  dried  preparations  (see 
Blood).  Loftier' s  method  also  reveals  them  readily.  An  aniline-water 
gentian-violet  fluid  is  added  to  its  own  bulk  of  solution  of  potash 
1  :  10,000.  The  cover-glass  is  immersed  for  five  minutes  in  the  fluid. 
It  is  then  removed  and  placed  in  a  1  per  cent,  solution  of  acetic  acid 
for  one  minute.  The  acetic  acid  should  be  tinged  slightly  yellow  with 
tropseolin.      The  preparation  is  then  bleached  by  washing  in  a  solution 


170  GENERAL  DIAGNOSIS. 

containing  two  drops  of  concentrated  sulphuric  acid  and  one  of  a  5  per 
cent,  solution  of  oxalic  acid  in  10  c.c.  of  water.  The  bacillus  is  also 
obtained  from  the  pus  of  an  abscess.  Its  nature  is  determined  by  the 
above  methods.  It  may  be  cultivated  and  inoculated  in  obscure  cases. 
Growth  When  cultivated,  the  wet  cultivation  crop  has  the  appearance 
of  a  grayish-white  drop.  Oo  a  potato,  at  a  temperature  of  35°  C,  it 
grows  as  a  thin  greasy  coating  of  a  dark  honey  or  amber  color.  On 
blood-serum,  at  a  low  temperature,  small  scattered  transparent  drops, 
the  color  of  the  serum,  are  seen.  It  also  grows  upon  glycerin  agar- 
agar  and  in  nutrient  milk-peptone.  Field-mice  and  guinea-pigs  are 
readily  infected  by  inoculation  with  pure  cultures.  For  the  diagnosis 
of  glanders  the  method  of  Strauss  should  always  be  resorted  to.  It  is 
to  inject  or  introduce  into  the  peritoneal  cavity  of  a  male  guinea-pig  a 
bit  of  the  suspected  material.  If  it  is  glandrous  in  nature,  the  animal 
will  exhibit  after  thirty  to  thirty-six  hours  a  swelling  of  the  testicle, 
which  progresses  to  the  stage  of  a  true  purulent  orchitis.  If  not 
glandrous,  no  such  lesion  occurs. 

9.  Bacillus  of  Anthrax.  The  pus  is  derived  from  the  carbuncle 
in  this  disease  (see  Blood).  Cultivations  may  be  resorted  to,  but  it  can 
readily  be  recognized  by  the  usual  methods  of  staining.  (See  Plate  I., 
Fig.  2,  a,  and  Plate  X.,  Fig.  1.)  Growth.  In  the  nutrient  gelatin 
medium  the  bacillus  develops  in  twenty- four  to  thirty-six  hours.  With 
the  magnifying-glass  the  scarcely  visible  minute  points  are  seen  to  be 
made  up  of  colonies  of  an  irregular  undulating  outline,  dark  in  color. 
After  forty-eight  hours  their  shape  is  more  characterisitc,  and  then  the 
cultivation  begins  to  liquefy,  stretching  over  the  surface  of  the  plate  in 
wavy  stripes.  On  a  sterilized  potato  it  forms  a  whitish-gray,  felt-like 
patch  of  uneven  surface,  scarcely  extending  over  the  site  of  inoculation. 
On  blood-serum  the  superficial  coating  of  white  color  is  formed.  On 
nutrient  gelatin,  delicately  interwoven  white  threads,  followed  by  lique- 
faction of  the  gelatin,  are  seen.  In  drop-cultivations  in  nutrient  broths 
long  shreds  develop  at  regular  intervals.  Inoculation  of  the  bacillus 
causes  symptoms  of  splenic  fever,  and  the  organism  is  found  in  the 
blood,  the  site  of  inoculation,  and  all  the  internal  viscera. 

10.  The  Bacillus  of  Leprosy.  The  micro-organism  is  found 
in  the  nodes  on  the  skin  and  mucous  membrane.  When  they  break 
down  abundant  thin  pus  is  poured  out.  The  bacilli  are  found  in  large 
numbers.  They  are  in  the  form  of  rods  4  to  6//  and  1/j.  in  breadth,  and 
resemble  the  bacillus  of  tubercle.  They  stain  in  alkaline  fluids,  but  do 
not  bleach  after  subsequent  exposure  to  acids.  They  stain  readily  (see 
Sputum).  A  dry  cover-glass  preparation  must  be  made  and  the  pus 
stained  with  the  Ziehl-JSTeelsen  fluid  (carbol-fuchsin)  and  then  decolor- 
ized in  acid  and  alcohol.  It  is  said  that  the  disease  has  been  produced 
by  inoculation  and  that  the  bacillus  has  been  cultivated,  although  not 
for  diagnostic  purposes.      (Plate  II.,  Fig.  2,  b.) 

11.  The  Bacillus  of  Tetanus.  The  bacillus  is  seen  as  a  deli- 
cate, slender  rod,  with  a  terrniual  spore.  It  stains  Avith  aniline  dyes 
and  Gram's  fluid.  Cultivations  may  be  made  Avith  the  pus.  It  should 
be  smeared  over  the  surface  of  slanted  agar-agar  or  blood-serum  in  a 
sterilized  tube,  placed  at  37°  C,  for  twenty-four  hours,  then  heated 


EXUDATIONS,  TRANSUDATIONS,  AND  CYSTIC  FLUIDS.     171 

to  80°  C.  in  a  water-bath  from  forty-five  to  sixty  minutes.  At  the  end 
of  this  time  gelatin  plates  or  Esmarch  tubes  are  to  be  made  from  the 
growth  in  the  heated  tube;  these  are  to  be  kept  in  an  atmosphere  of 
pure  hydrogen  at  20°  to  22°  C.  Growth  is  favored  by  the  addition  to 
the  gelatin  of  2  per  cent,  of  glucose.  If  the  inoculation  be  made  as  a 
stab  in  a  tube  about  three-quariers  filled  with  gelatin,  growth  is  seen 
only  to  within  about  2  cm.  of  the  surface  of  the  media.  Faint  radi- 
ating striae  or  thorn-like  processes  are  seen.  The  development  is  rapid 
in  agar-agar.  After  an  exposure  of  thirty  hours  to  a  temperature  of 
37°  C.  the  spores  make  their  appearance.  On  gelatin  the  colonies  are 
dense  at  the  centre  with  a  more  delicate  periphery.  The  preparation 
becomes  fluid  and  gas  is  evolved.     It  is  strictly  anaerobic. 

12.  Bacillus  of  Influenza.     (See  Sputum.) 

13.  Micrococcus  Lanceolatus.  Pneumococci.  The  pneuino- 
coccus  has  been  frequently  found  in  the  pus  of  empyema,  whether  from 
the  pleural  cavity  or  after  it  has  burrowed  from  this  situation.  It  occurs 
in  epidemic  cerebro-spinal  meningitis.  It  is  easily  detected  by  the 
usual  staining-methods  (for  Avhich  see  Sputum). 

14.  Bacillus  Coli  Communis.  The  bacillus  coli  communis  is 
found  in  suppurations  within  the  abdominal  cavity  (see  Faeces). 

15.  The  Gonococcus.  It  is  constantly  present  in  virulent  gon- 
orrhoeal  pus,  usually  within  the  pus-cell,  or  attached  to  the  sur- 
face of  epithelial  cells.  Morphology.  Micrococci,  usually  joined  in 
pairs  or  fours,  flattened  and  separated,  when  stained,  by  an  un- 
stained intercellular  space.  Stains  easily  with  anilines  —  not  by 
Gram' s  method. 

No  other  cocci  are  of  the  same  shape,  and  at  the  same  time  within 
the  cells,  except  one  which,  however,  stains  by  Gram's  method.  (See 
Plate  II.,  Fig.  3,  6.) 

Growth.  Does  not  grow  readily  on  ordinary  media,  but  can  be  cul- 
tivated on  blood-serum  and  other  special  media,  such  as  urine,  agar, 
etc. ;  30°  to  40°  C  is  best,  and  a  moist  atmosphere  is  needed. 
Growth  is  slow  and  often  fails.  Forms  a  thin,  scarcely  visible  layer, 
with  smooth,  shining  surface,  grayish-yellow  by  reflected  liglit- — is 
aerobic. 

Inoculation  into  the  human  urethra  produces  a  typical  attack  of 
gonorrhoea. 

Protozoa  in  the  Pus  Cercomonads  have  been  observed  in  the 
pus  of  an  empyema,  probably  from  the  lungs.  Flexner  has  found  the 
amoeba  dysenterica  in  the  pus  of  an  abscess  of  the  jaw.  It  is  found  in 
abscess  of  the  liver  and  secondary  abscess  of  the  lung  (see  Sputum  and 
Feeces). 

Vermes.  Filaria  have  been  found  in  abscess  of  the  liver.  In  the 
suppuration  of  hydatids  the  pus  contains  membrane  and  booklets. 

Crystals.  Crystals  of  oholesterin  are  found  in  the  pus  from  cold 
abscesses,  suppurating  ovarian  cysts,  and  foetid  discharges.  They  arc 
similar  to  the  crystals  described  under  sputum. 

Hcematoidin-crystals  indicate  a  previous  hemorrhage;  they  arc  most 
frequent  in  suppurating  hydatid  cysts.  ■  (See  Fig.  20.)  Fully  mrd/rs 
are  found  in  old  pus  and  gangrenous  exudates.      (Sec  Fig.  21.)      Triple 


172 


GENERAL  DIAGNOSIS. 


phosphates  are  frequently  seen  in  pus  and  are  of  the  same  appearance 
as  the  phosphates  in  the  urine.  The  carbonates  and  phosphates  are 
seen  in  foetid  pus. 


Fig.  20. 


Fig.  21. 


Rhombic  crystals  of  heemin.    (Charles.) 


Pus  from  putrid  empyema.  (Eye-piece 
in.,  obj.  8,  A.  Reichert.)  Shrunken  leu- 
cocytes.   Fat-crystals.    (Von  Jaksch.) 


Chemical  Examination  of  Pus.  This  does  not  yield  any  infor- 
mation of  diagnostic  value. 

Serum-albumin,  globulin,  and  peptone  are  detected  by  methods  em- 
ployed in  the  examination  of  urine.  Fresh  pus  contains  sugar.  After 
being  boiled  with  an  equal  weight  of  sulphate  of  soda  and  filtered  the 
filtrate  is  examined  by  the  reagents  used  in  examination  of  urine  for 
sugar.  Pus  also  contains  bile-pigments  and  biliary  acids,  cholesterin 
and  salts  of  sodium  and  the  fatty  acids  in  jaundice.  Von  Jaksch  has 
found  acetone  in  pleural  exudations. 

Sero-purulent  Exudations.  They  resemble  purulent  discharges 
chemically  and  morphologically.  They  point  to  antecedent  inflamma- 
tion. 

Putrid  Exudations.  The  exudations  are  brown  or  brownish- 
green  in  color.  The  odor  is  penetrating  and  offensive.  They  are  usually 
alkaline  in  reaction  On  microscopical  examination,  old  leucocytes  and 
crystals  of  fat,  cholesterin,  and  hsematoidin  are  seen;  fission-fungi  of 
various  forms  are  seen.     (See  Figs.  20  and  21.) 

Hemorrhagic  Exudations.  Hemorrhagic  exudations  contain  red 
blood-corpuscles  and  hemoglobin  in  large  amount.  Fatty  endothelial 
cells  are  found.  Quincke  "states  that  when  the  glycogen-reaction  is 
shown,  if  the  fluid  is  from  the  pleura,  carcinoma  is  probably  present. 
A  positive  diagnosis  depends  upon  the  discovery  of  the  epithelial  cells 
(see  p.  173),  which  are  seen  in  cases  of  cancer.  Hemorrhagic  exuda- 
tions in  the  pleura  are  clue  most  frequently  to  cancer,  to  tubercle,  or  to 
scurvy.  To  determine  its  exact  nature  (as  to  tubercle),  inoculation  and 
cultures  are  sometimes  necessary.     (See  Fig.  15.) 

Serous  Exudations.  The  fluid  is  clear  and  light  yellow  or  straw- 
colored.  On  standing  a  white  fibrinous- clot  is  deposited.  On  micro- 
scopical examination,  red  blood-corpuscles,  leucocytes,  fatty  globules, 
and  endothelial  cells  are  found.  They  may  be  bunched  in  groups  or 
scattered  about.  The  micro-organisms,  if  present,  are  detected  with 
difficulty.  If  ulcerating  tuberculosis  of  the  pleura  is  present,  the 
bacillus  may  be  found,  but  tuberculous  pleurisy  may  exist  without  ulcer- 


EXUDA TIONS,  TRANSUDATIONS,  AND  CYSTIC  FL  UIDS.     1 73 

ation,  and  hence  the  fluid  is  clear  of  the  bacillus.  Cholesterin-crystals 
are  found  in  old  serum.  On  chemical  examination  the  fluid  contains 
more  than  3  per  cent,  of  serum-albumin  and  globulin;  peptone  is 
absent  in  pleural  exudations  ;  sugar  in  small  amount  and  acetone  are 
found. 

The  specific  gravity  of  the  fluid  is  above  1018. 

Chylous  Exudations.  Sometimes  in  peritoneal  exudation,  par- 
ticularly if  the  patient  has  been  upon  a  milk-diet,  the  fluid  contains 
fatty  matter  which  gives  it  a  milky  appearance.  The  same  character 
of  fluid  is  seen  in  obstruction  of  the  thoracic  duct.  True  chyle  is 
found  in  fluids  of  low  specific  gravity.  Such  ah  effusion  is  rich  in  fat 
and  is  due  to  leakage  of  lymphatics  into  the  peritoneal  cavity.  It  is 
known  as  a  chylous  effusion.  Chyliform  effusion  is  a  term  applied  to 
the  effusion  first  mentioned  in  this  section.  The  fluid  has  the  property 
of  chyle. 

Special  Effusions.  Effusion  in  the  Pleura.  It  is  of  the  greatest 
importance  to  distinguish  the  various  forms  of  infection.  Bacteriological 
examination  is  often  necessary.  In  purulent  exudation,  if  micro-organ- 
isms are  absent  (staphylococcus  and  streptococcus),  it  is  probably  tuber- 
culous; serofibrinous  exudations  are  usually  free  from  fungi.  When 
the  micrococcus  lanceolatus  is  found,  it  is  of  favorable  prognostic  omen. 

To  distinguish  the  effusion  of  inflammation  from  that  of  transudation 
(obstruction)  the  specific  gravity  is  of  service.  In  the  inflammatory 
effusions  the  specific  gravity  is  high;  they  also  contain  a  large  amount 
of  fibrin  and  more  than  3  per  cent,  of  albumin. 

Transudations.  This  class  of  fluids  is  serous,  bloody,  or  chylous. 
The  specific  gravity  is  lower  than  in  inflammatory  effusion.  The  color 
is  light  and  the  reaction  usually  alkaline.  On  microscopical  examina- 
tion but  little  is  found.  In  pleuritic  effusions  there  may  be  consider- 
able endothelium  which,  if  mixed  with  blood,  may  be  due  to  carcinoma. 
Serum  contains  albumin  and  sugar,  the  former  in  great  excess.  Pep- 
tone is  always  absent.     The  fluid  coagulates  with  difficulty  on  boiling. 

Contents  of  Cysts.  In  aspiration  of  the  abdomen  and  of  the 
pleura  cysts  are  sometimes  evacuated,  the  nature  of  which  is  often 
determined  by  an  examination  of  the  fluid.  It  is  within  the  province 
of  this  work  to  discuss  hydatid  cysts,  pancreatic  c*Tsts,  and  the  cystic 
kidney.  As  tumors  of  the  ovary  so  frequently  resemble  tumors  in 
other  situations,  it  is  well  also  to  discuss  in  this  section  the  nature  of 
the  fluid  withdrawn  from  them. 

Hydatid  Cyst.  The  fluid  of  hydatid  cysts  is  clear,  alkaline,  and  of  a 
specific  gravity  of  1010.  It  contains  chloride  of  sodium  in  excess,  gra]  >e- 
sugar  in  small  amount,  and  very  little,  if  any,  albumin.  On  micro- 
scopical examination  hooklets  are  found,  as  in  the  sputum  from  hydatid 
cyst  of  the  lung,  as  well  as  portions  of  membrane.  The  membrane 
is  recognized  by  its  peculiar  transverse  striation  and  the  granular  appear- 
ance of  its  inner  surface.  The  heads  or  scolices  are  sometimes  found. 
Two  circles  of  hooklets  and  four  disks  on  the  anterior  aspect  cross  the 
head,  which  is  separated  from  the  hinder  part  by  an  annular  constriction 


174 


GENERAL  DIAGNOSIS. 


(see  Sputum  and  Fseces).  If  suppuration  has  taken  place,  the  original 
nature  of  the  cyst  cannot  be  made  out  unless  hooklets  are  found.  After 
the  fluid  has  been  standing  in  a  conical  glass  vessel  the  bodies  may  be 
found  in  the  sediment. 

Ovarian  Cysts.  The  fluid  from  an  ovarian  cyst  is  of  high  specific 
gravity,  1026,  of  alkaline  reaction,  contains  but  a  small  amount  of 
albumin,  and  does  not  coagulate.  On  microscopical  examination  vari- 
ous forms  of  epithelial  cells  are  seen,  colloid  bodies,  and  cholesterin- 
crystals.  If  hemorrhage  has  taken  place  in  the  cyst,  the  color  of  the 
fluid  is  correspondingly  changed,  and  besides  the  squamous,  columnar, 
and  ciliated  varieties,  some  epithelium  in  the  stage  of  fatty  degenera- 
tion, and  red  and  white  blood-corpuscles  are  seen.  In  colloid  cysts  the 
usual  concretions  are  found.     (See  Fig.  22.) 


Fig.  22. 


Contents  of  an  ovarian  cyst.  (Eye-piece  III.  obj.  8,  A.  Reichert.)  a,  squamous  epithelial  cells  ■- 
b,  ciliated  epithelial  cells ;  c,  columnar  epithelial  cells ;  d,  various  forms  of  epithelial  cells ;  e,  fatty 
squamous  epithelial  cells  ;  /,  colloid  bodies  ;  g,  cholesterin  crystals.    (Von  Jaksch.) 

In  dermoid  cysts,  in  addition  to  the  above,  squamous  epithelium, 
hairs,  and  fatty,  hsematoidin,  and  cholesterin  crystals  are  detected. 
Ovarian  fluid  contains  albumin  and  methsemoglobin,  or  paralbumin. 
The  latter  is  detected  by  mixing  a  portion  of  the  fluid  with  three  times 
its  bulk  of  alcohol.  It  is  then  allowed  to  stand  for  twenty-four  hours, 
when  it  is  filtered.  The  precipitate  is  removed  and  suspended  in  water. 
After  filtering,  the  filtrate  is  seen  to  be  opalescent  and  is  tested  as  fol- 
lows : 

1.  On  boiling  no  precipitate  is  formed,  but  the  fluid  becomes  turbid. 

2.  There  is  no  change  with  acetic  acid  alone. 

3.  The  fluid  becomes  thick  and  of  a  yellowish  tint  when  treated  with 
acetic  acid  and  ferrocyanide  of  potassium. 

4.  There  is  a  change  to  a  violet  color  when  treated  with  concentrated 
sulphuric  and  acetic  acids. 


EXUDATIONS,  TRANSUDATIONS,  AND  CYSTIC  FLUIDS.     175 

Some  observers  differ  from  the  above  statement  in  their  description 
of  the  fluid  of  ovarian  cyst ;  all  agree  as  to  the  large  number  of  cell- 
elements.  At  one  time  it  was  thought  that  the  fluid  contained  a  special 
cell,  but  this  view  has  been  abandoned.  In  rare  cases  the  specific 
gravity  may  be  lower  than  that  of  the  fluid  of  ordinary  ascites.  A 
fluid  of  low  specific  gravity,  with  a  small  amount  of  albumin,  is  said 
to  be  characteristic  of  a  cyst  of  the  broad  ligament. 

Cydic  Kidney.  The  fluid  from  a  cystic  kidney  can  be  recognized  by 
the  properties  it  derives  from  the  renal  secretion.  Urea  and  uric  acid 
in  large  amounts  point  to  its  true  source.  Renal  epithelium  is  of  the 
greatest  diagnostic  value  (see  Urine).  If  epithelium  from  the  urinary 
tubules  can  be  detected  after  the  fluid  has  settled,  the  diagnosis  is  abso- 
lute (see  Hydronephrosis).  It  must  not  be  forgotten  that  both  urea 
and  uric  acid  may  be  found  in  other  cysts,  as  in  those  of  the  ovary,  if 
they  communicate  with  the  urinary  tract. 

Pancreatic  Cysts.  Recently  fluid  from  cysts  of  the  pancreas  has 
been  examined  and  shown  to  be  of  diagnostic  value  in  determining  the 
nature  of  the  abdominal  tumor.  The  fluid  is  of  a  specific  gravity  of 
1012,  but  may  be  as  high  as  1028.  It  contains  cholesterin-crystals  in 
abundance,  and  blood  or  pigment.  Serum-albumin  is  present,  but 
metalbumin  is  not  found.  The  diastatic  ferment  is  present.  This 
may  be  met  with  in  the  fseces  and  in  the  secretions  of  the  mouth.  If 
on  examination  for  sugar  the  latter  is  found  to  be  a  maltose,  its  presence 
is  of  diagnostic  significance. 

The  most  pronounced  property  of  the  pancreatic  fluid,  and  that  by 
which  we  are  enabled  to  distinguish  it  from  other  fluids,  is  the  power 
of  digesting  albumin  without  the  presence  of  an  acid. 

Boas  (Deutsche  med.  Wochenschr.,  1890,  Bd.  xvi.  p.  1095)  devel- 
oped the  method  of  examination.  The  fluid  is  to  be  added  to  milk  ; 
after  the  casein  is  precipitated  the  biuret-test  is  applied.  Heat  the 
substance  with  caustic  potash  and  add  drop  by  drop  a  10  per  cent, 
solution  of  sulphate  of  copper.  If  digested  albumin  is  present,  the  fluid 
assumes  a  reddish-violet  color.  No  other  cystic  fluid  can  dissolve  albu- 
min in  alkaline  solution.  The  pancreatic  fluid  also  emulsifies  fats.  In 
large  cysts,  however,  particularly  if  of  long  standing,  the  physiological 
properties  of  the  pancreatic  juice  are  sometimes  wanting.1  In  the  case 
referred  to  by  Boas  and  reported  by  Karewski,  the  old  age  of  the  cyst 
modified  the  character  of  the  fluid,  and  hence  rendered  its  nature  doubt- 
ful. Moreover,  in  the  exploratory  puncture  the  stomach  was  pene- 
trated. For  two  reasons  the  author  advises  against  exploratory  puncture. 
First,  the  age  of  the  cyst  is  not  known,  hence  an  analysis  would  be 
misleading.  Second,  the  danger  of  puncturing  other  organs  is  too 
great.     Exploratory  laparotomy  is  preferable. 

1  In  a  case  operated  on  by  Penrose  the  analysis  of  the  fluid  was  as  follows  :  Sp.  gr.  1025.    Reac- 
tion  slightly  alkaline.     Serum-albumin;  no  metalbumin.     Diastatic  ferment  absent;    E 
absent.    By  Boas'  method  power  to  digest  albumin  was  marked,  but  when  the  albumin  rem 
in  the  filtrate  was  removed  from  the  pancreatic  fluid,  it  failed  to  show  that  peptone  was  formed. 
The  metiiod  appears  to  be  fallacious,  therefore.    The  cyst  was  old  and  the  fluid  no  doubt 
physiological  properties.    Cholesterin  was  present  in  enormous  amount ;  tyrosin-crystals  were  very 
scarce. 


CHAPTER  YT. 

THE   MORBID   PEOCESSES   AND   THEIR   SYMPTOMATOLOGY. 

Knowledge  of  symptoms  of  morbid  processes  essential ;  they  control  conclusions  drawn 
from  data. — Morbid  processes  are  few.  I.  Alterations  in  blood  and  circulation  : 
Anaemia  and  plethora — Hyperemia,  active  and  passive — (Edema  and  dropsy 
— Thrombosis  and  embolism — Hemorrhage — Blood-pressure.  II.  Disturbances 
of  nutrition:  Inflammation — Gangrene  and  necrosis  —  Fever — Atrophy  and 
hypertrophy.  Degenerations  :  Albuminous — Fatty — Colloid — Mucous — Pig- 
mentary— Calcareous — Amyloid — Fibroid.  III.  Anomalies  of  growth :  Tumors 
— Cysts — Cancer. 

Although  we  may  have  secured  all  the  data  obtainable  by  inquiry 
and  by  observation,  and,  if  possible,  made  a  diagnosis  based  upon  them, 
it  frequently  happens  that  the  conclusion  arrived  at  is  not  final  and  per- 
haps cannot  be,  from  the  nature  of  the  case.  We  are  prompted,  there- 
fore, to  view  the  case  from  a  different  standpoint,  to  utilize  our  knowl- 
edge of  the  phenomena  of  morbid  processes,  and  for  the  purpose  of 
comparison  to  review  the  features  of  such  as  apparently  resemble  the 
process  under  consideration.  Thus,  for  instance,  in  an  obscure  case 
of  fever,  the  objective  and  subjective  phenomena  have  been  fully 
inquired  into  :  we  are  unable  to  decide  whether  the  disease  under  con- 
sideration is  a  septic  process  with  obscure  lesion,  a  form  of  miliary 
tuberculosis,  or  of  malignant  endocarditis.  The  known  symptoms  of 
each  are  considered  (our  knowledge  of  such  symptoms  depending  upon 
our  knowledge  of  the  phenomena  of  the  respective  morbid  process) 
and  compared  with  the  symptoms  presented  by  the  case  in  question. 
In  this  manner  a  diagnosis  by  exclusion  is  made.  Moreover,  after  a 
diagnosis  is  made  a  review  of  the  symptomatology  of  morbid  processes 
serves  as  a  check  upon  the  conclusions  that  have  been  reached.  We 
should  also,  after  making  a  diagnosis,  compare  the  symptoms  of  the 
process  as  exhibited  in  the  patient  with  the  symptoms  which  we  know 
to  be  common  in  the  suspected  disease. 

It  is  necessary,  therefore,  that  the  student  should  fully  know  the 
symptoms  of  morbid  processes.  Each  process  is  characterized  by 
special  phenomena  by  which  it  can  be  recognized.  The  symptoms  are 
modified  by  the  function  and  anatomical  structure  of  the  organ  in 
which  the  process  takes  place.  Thus  the  pathological  products  of  in- 
flammation of  the  mucous  membranes  of  the  bronchial  tubes  and  of 
the  stomach  are  the  same,  but  the  symptoms  differ,  because  of  the  dif- 
ference in  their  functions,  and  hence  we  have  cough  in  the  former 
case,  in  the  latter,  vomiting.  Very  frequently  the  symptoms  differ 
because  of  the  physical  alterations.  Thus  inflammation  of  the  peri- 
cardium is  similar  to  iuflammation  of  the  pleura,  but  the  pressure- 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     177 

symptoms  of  pericarditis  are  entirely  different,  because  of  the  anatomi- 
cal relations,  from  the  pressure-symptoms  of  pleuritis. 

The  morbid  processes  are  not  many.  They  include  :  I.  Alterations 
in  the  blood  and  circulation  ;  II.  Disturbances  of  nutrition  ;  III. 
Anomalies  of  growth. 

I.  Alterations  in  the  Blood  and  Circulation.  The  composition 
and  distribution  of  the  blood  affect  all  the  tissues  for  weal  or  woe. 
The  quantity  of  the  blood  alone  will  be  referred  to;  changes  in  quality 
will  be  considered  under  diseases  of  the  blood.  Practically  the  symp- 
toms, when  the  quality  is  affected,  are  those  of  ancemia  plus  the  symp- 
toms (physical  and  functional)  of  the  primarily  diseased  organ — as  the 
spleen  in  leucocythaernia.  The  quantity  may  be  increased  or  dimin- 
ished. 

1.  Increased  Quantity  of  Blood,  or  Plethora.  Formerly  this 
was  considered  an  entity,  and  the  symptoms  of  flushed  face,  hot  and 
full  head,  throbbing  pain,  throbbing  temporals,  a  full,  strong  pulse, 
sluggish  intellect,  were  thought  to  indicate  an  excess  of  the  general 
bulk  of  the  blood.  True  plethora  is  rarely  permanent.  If  transitory, 
the  veins  and  not  the  arteries  are  overfilled.  The  symptoms  are  not 
due  to  general  plethora,  but  to  excess  of  blood-pressure  or  to  special 
fluxions  of  blood  to  superficial  vessels,  determined  by  a  nervous  mech- 
anism. Increase  in  one  of  the  cellular  elements  of  the  blood,  the 
leucocytes,  is  not  a  plethoric  condition. 

2.  Diminished  Quantity  op  Blood,  or  Anjemia.  Anaemia 
embraces  the  diminution  of  the  bulk  of  the  blood  as  well  as  of  the 
red  blood-cells  and  their  haemoglobin. 

The  term  might  be  used  for  loss  of  the  water  of  the  blood,  as  in 
cholera  Asiatica  (see  Infectious  Diseases),  or  in  serous  purging.  The 
symptoms  are  those  of  collapse. 

Oligemia  or  spanaemia  are  terms  that  may  be  used  to  define  the 
general  thinness  or  poverty — atrophy  of  the  blood.  Clinically,  anaemia 
is  divided  into  simple  anaemia,  general  poverty  of  the  blood  ;  perni- 
cious or  idiopathic  anaemia,  reduction  in  the  number  of  red  cells;  chlo- 
rosis, reduction  in  the  quantity  of  haemoglobin;  leucocythaemia,  relative 
loss  of  red  and  increase  of  white  corpuscles.  (See  Diseases  of  the 
Blood.) 

3.  Local  Disturbance  of  the  Circulation.  A.  HYPERiEMiA, 
or  Congestion.  The  process  may  be  acute  or  chronic.  It  is  usually 
local,  although  it  may  be  general.  When  the  latter,  many  organs  may 
be  simultaneously  involved  from  a  common  cause. 

Symptoms.  The  acute  or  active  form  of  hyperaemia  is  always  local 
and  arterial.  There  is  an  excess  of  blood  in  the  part.  If  the  skin 
is  the  seat,  there  are»redness  and  increased  heat,  and  throbbing  or  pulsa- 
tion may  be  seen.  The  parts  are  swollen.  The  excitability  of  the 
nerves  is  increased,  with  local  symptoms  of  warmth,  fulness  or  itching. 
The  morbid  blushing,  or  flushing,  that  occurs  at  the  menopause  or 
refiexly  from  internal  disorder,  is  a  hyperaemia,  and  in  erythema  of 
the  skin  hyperaemia  is  also  very  marked. 

Causes.      Arterial  hyperaemia  is  caused  by  (1)   neuro-paralysis  of 

12 


178  GENERAL  DIAGNOSIS. 

the  inhibitory  or  vaso-constrictor  fibres,  of  the  cervical  sympathetic, 
splanchnic,  and  other  sympathetic  and  some  mixed  nerves,  as  the 
sciatic  ;  (2)  neuro-tonic  stimulation  of  the  actively  dilating  or  vaso- 
dilator nerves,  as  the  chorda  tympani.  There  is  relaxation  of  the 
arterial  walls.  This  may  also  occur  directly  through  the  vasomotor 
system,  being  induced  by  heat,  electricity,  or  chemical  irritants,  or 
from  paralysis  of  muscular  fibres,  after  spasmodic  contraction  due  to 
cold,  as  in  frost-bite. 

Causes  and  Symptoms  of  X euro-paralytic  Hyperemia. 
Destruction  of  the  cervical  sympathetic  nerve  by  abscess,  wounds, 
or  a  tumor  pressing  upon  it,  produces  hyperemia  of  the  side  of  the 
face,  ri-e  of  temperature,  and  contraction  of  the  pupil.  Later  on,  the 
vascular  condiiions  are  reversed.  Lesion  of  the  fifth  nerve,  or  one  of 
its  branches,  causes  hyperemia  of  the  iri-j,  the  conjunctiva,  the  cheek, 
the  gums,  and  other  structures  supplied  by  it,  with  associate  lo-vS  of 
sen-ation  followed  by  atrophy.  The  sensory  symptoms  have  nothing 
to  do  with  the  vascular  paralysis. 

N  euro-tonic  Hyperemia.  After  wounds  of  the  brachial  plexus 
hyperemia  of  the  fingers  is  seen.  (See  Fingers.)  The  local  tempera- 
ture rises,  and  there  is  neuralgic  pain.  Local  hyperemia  with  hyper- 
esthesia, known  as  erythromelalgia,  belongs  to  the  same  class,  being 
due  to  affections  of  the  nerve-trunks,  or  the  peripheral  nerve-endings. 
It  must  be  remembered  that  a  reflex  hyperemia  is  possible. 

Chronic  or  Venous  Hyperemia  (passive  congestion).  The 
blood  accumulates  in  the  veins,  and,  by  backward  pressure,  in  the 
capillaries.  The  venous  capillaries  are  overdistended  and,"  as  com- 
pared with  the  arterial,  much  enlarged.      They  contain  venous  blood. 

Any  congested  part,  as  the  exterior,  is  bluish  or  purple  in  tint,  often 
swollen  (clubbed  fingers),  cooler  than  normal,  with  lessened  sensation, 
and  without  pulsation.  (See  Cyanosis.)  The  dependent  parts  are  first 
affected,  as  the  legs,  or  the  lungs.  In  fevers  a  weak  heart  and  recum- 
bent posture  predispose  to  congestion  of  the  lungs. 

Causes.  Obstructive  heart  and  lung  diseases  cause  general  venous 
congestion.  Local  venous  congestion  is  caused  by  tumors,  the  pregnant 
uterus,  or  collections  of  feces  pressing  upon  the  veins.  It  is  also  caused 
by  inflammation  of  the  vein-!,  and  thrombosis. 

B.  Local  Anjemia.  This  may  be  due  to  arterial  thrombosis  or 
embolism,  arterial  obstruction  through  endarteritis,  or  to  arterial  spasm. 
Raynaud's  disease  is  a  form  of  arterial  spasm.  The  grave  effects  of 
arterial  obstruction  are  seen  in  cerebral  anemia  from  endarteritis,  or 
myocarditis  from  obstruction  of  the  coronary  arteries. 

C.  (Edema  and  Dropsy.  The  changes  of  the  circulation  which 
produce  these  conditions  have  been  referred  to  in  the  third  chapter  of 
this  book.  The  symptoms  and  signs  of  the  condition  are  also  noted  in 
the  same  section. 

D.  Thrombosis  and  Emboltsm.  The  student  should  be  familiar 
with  the  symptoms  of  these  conditions,  and,  what  is  fully  as  important, 
with  the  causes  that  give  rise  to  them.  Thrombi  may  form  in  the 
heart,  the  arteries,  or  the  veins.  Emboli  may  be  formed  in  either 
heart  or  vessels,  but  lodge  in  the  vessels  only. 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     179 

Thrombosis.  The  symptoms  of  thrombosis  are  :  1.  Mechanical.  The 
channel  is  obstructed;  hyperemia,  engorgement,  oedema,  and  cyanosis 
arise.  Its  most  typical  form  is  seen  in  femoral  thrombosis,  with  cya- 
doss.  and  oedema  of  the  leg.  When  an  artery  is  obstructed  the  symp- 
toms are  like  those  of  occlusion  under  other  circumstances  (see  Eintiol- 
ism);  when  a  vein,  the  mechanical  symptoms  vary  according  to  the 
particular  vein  affected.  Thus,  in  thrombosis  of  the  coronary  vein, 
the  heart's  action  is  interfered  with;  of  the  portal  vein,  jaundice  (not 
because  of  the  obstruction),  oedema  (ascites),  congestion  (gastric  and 
intestinal)  occur,  as  in  obstruction  in  any  vein  ;  thrombosis  of  the 
cerebral  veins,  disturbance  of  the  function  of  the  brain  ;  of  the  pul- 
monary veins,  dyspnoea.  2.  Inflammatory  or  septic.  If  it  should 
happen  that  the  thrombosis  developed  secondarily  to  an  inflammation 
of  septic  origin,  as  in  the  extension  of  an  inflammation  into  the  radicles 
of  the  portal  vein  from  an  abscess  about  the  rectum  or  vermiform 
appendix,  the  liver  would  be  infected  with  micro-organisms.  An 
infectious  inflammation  with  chills,  fever,  sweats,  and  other  phenomena 
of  a  septic  character  would  result.  3.  Embolic.  From  the  thrombus 
emboli  are  sometimes  swept  off  ;  hence,  embolic  symptoms  arise  in 
the  course  of  thrombosis. 

While  thrombosis  is,  as  a  rule,  easily  recognized,  it  is  necessary  to 
call  attention  to  the  very  great  importance  of  going  a  step  farther  to 
look  for  the  cause.  A  thorough  knowledge  of  the  causes  of  thrombosis 
often  leads  to  the  diagnosis  of  a  thrombus  when  without  such  knowl- 
edge its  presence  would  never  have  been  suspected.  The  causes  are 
not  many.  1.  Stagnation  or  stoppage  of  blood.  It  is  seen  chiefly  in 
the  veins  and  the  heart.  External  pressure  upon  the  veins  :  as  upon 
the  pelvic  veins  in  pregnancy  or  abdominal  tumor,  upon  the  hemor- 
rhoidal veins,  upon  the  portal  veins  by  tumor,  upon  the  pulmonary 
veins  by  mediastinal  tumor.  It  must  be  remembered  that  some  change 
takes  place  in  the  internal  coat  of  the  vein  also,  but  that  the  pressure 
is  primary.  Then  w-e  have  weakness  of  the  heart  as  a  cause  of  stag- 
nation. Feeble  contractions  lead  to  the  formation  of  cardiac  thrombi. 
2.  Thrombosis  from  changes  in  the  vessel's  walls.  The  change  is 
usually  inflammatoiy  and  often  proceeds  from  wounds.  If  the  wound 
was  septic,  the  inflammation  will  be  septic.  In  the  heart,  endocarditis; 
in  the  aorta,  atheroma  leads  to  the  development  of  thrombi.  3.  Throm- 
bosis from  the  entrance  of  a  foreign  substance  into  the  vessels.  A 
carcinoma  or  other  new  growth  may  extend  into  the  veins.  Micro- 
organisms penetrate  the  vein  and  cause  inflammation  and  thrombosis, 
or  infect  a  previously  existing  thrombus.  The  clot  is  then  broken  and 
distributed  throughout  the  system,  causing  pyaemia.  4.  Thrombi  are 
produced  by  extension.  A  clot  enlarges  by  coagulating  the  blood  next 
to  it.  A  large  venous  distribution  may  become  blocked,  as,  first  the 
uterine  veins,  then  the  internal  iliac,  then  the  external  iliac,  and  after 
that  the  femoral — causing  the  affection  which  frequently  occurs  in  the 
puerperal  form,  phlegmasia  alba  dolens. 

Embolism.  An  embolus  is  a  substance  which  is  swept  into  and 
plugs  a  vessel.  It  may  be  a  fragment  of  a  blood-clot  (thrombus), 
vegetations  from  valves  of  the  heart,  parasites,   new  growths  which 


180  GENERAL  DIAGNOSIS. 

had  entered  the  veins,  fat,  or  air.  If  obstruction  of  the  vessel  alone 
is  produced,  the  embolism,  is  said  to  be  simple  ;  if  a  new  process, 
as  inflammation,  accompanies  the  obstruction,  it  is  specific.  Frag- 
ments from  a  thrombus  in  the  systemic  veins  may  become  an  embolus 
which  may  block  the  pulmonary  artery  ;  a  clot  or  portion  of  valve- 
leaflet  from  the  left  heart  may  block  a  systemic  artery,  as  a  cerebral 
vessel  or  the  femoral  vessel ;  a  clot  in  the  portal  vein  will  obstruct 
branches  in  the  liver. 

The  symptoms  occur  suddenly  and  depend  upon  the  artery  obstructed. 
The  cutting  off  of  the  blood-supply  causes  cessation  of  function  beyond 
the  point  of  obstruction.  In  pulmonary  venous  embolism  dyspnoea 
is  pronounced,  the  heart's  action  rapid  and  irregular,  and  many  cases 
are  said  to  be  "  heart- failure."  In  the  middle  cerebral  artery  the 
embolus  causes  aphasia  and  mono-  or  hemiplegia.  In  embolism  of  the 
pulmonary  artery  cough  and  hemorrhage  with  dyspnoea  occur  suddenly. 
The  patient  in  whom  this  occurs  usually  has  had  antecedent  mitral 
regurgitation  and  dilated  right  heart. 

The  blocking  of  an  artery  may  lead  to  various  symptoms.  If,  for 
instance,  the  main  artery  of  the  leg  is  blocked,  anastomosis  may  be 
set  up  ;  if  it  does  not,  gangrene  ensues.  If  an  artery  supplying  any 
internal  organ  is  blocked,  anastomosis  may  occur,  if  the  artery  is  not 
terminal.  If  the  artery  is  terminal,  there  results  rapid  necrosis  or 
softening,  as  in  the  brain;  gradual  wasting,  as  of  a  kidney,  or  engorge- 
ment of  the  arterial  area  and  diffuse  hemorrhage.  The  latter  is  known 
as  a  hemorrhagic  infarct.  This  may  occur  in  the  lungs  (pulmonary 
artery),  spleen,  kidneys,  retina,  and,  rarely,  the  intestinal  canal.  The 
symptoms  of  hemorrhagic  infarct  are  swelling  and  hemorrhage.  In  the 
lungs,  there  are  physical  signs  of  consolidation,  with  haemoptysis,  cough, 
and  dyspnoea  ;  in  the  kidneys,  pain  and  hematuria  ;  in  the  spleen, 
pain  and  at  times  enlargement ;  in  the  retina,  blindness  with  ophthal- 
moscopic changes  ;  in  the  intestine,  pain  and  hemorrhage  with  slough- 
ing of  mucous  membrane.  Infective  emboli  cause  abscesses.  Capillary 
embolism  is  seen  in  the  skin  and  mucous  membranes  in  many  infective 
diseases,  notably  ulcerative  endocarditis.  Fat-embolism  occurs  in  the 
pulmouary  capillaries,  and  is  due  to  fat-globules  which  sometimes  enter 
the  circulation  in  pregnant  women,  or  in  patients  with  bone  disease, 
as  osteomyelitis,  or  fractures.  The  symptoms  are  those  of  intense 
dyspnoea.  It  may  cause  sudden  death.  Air-embolism.  Air  may  enter 
wounds  of  the  veins  of  the  neck.  It  accumulates  in  the  heart,  and 
as  the  ventricle  cannot  contract  on  it  the  blood  is  not  propelled. 
Death  takes  place  with  the  symptoms  of  heart-clot,  the  heart  being 
in  asystole. 

Hemorrhage.  Hemorrhage  may  be  arterial,  venous,  or  capillary. 
It  may  occur  because  the  blood  soaks  through  the  walls,  by  diapedesis; 
or  it  may  occur  from  rupture,  or  rhexis.  Hemorrhage  by  diapedesis 
takes  place  in  venous  engorgement,  stasis,  or  inflammation.  It  is  the 
small  passive  hemorrhage  of  congestion,  as  in  pulmonary  congestion 
from  heart  disease  ;  it  is  venous  or  capillary;  the  blood  is  dark.  Hem- 
orrhage by  rupture  is  arterial,  venous,  or  capillary.  If  the  artery  rup- 
tures, it  has  been  torn  by  violence,  destroyed  by  ulceration  or  suppura- 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     181 

tion,  or  it  is  the  seat  of  endarterial  change.  Veins  are  also  diseased, 
or  their  Avails  destroyed,  before  rupture  takes  place.  Rupture  of  capil- 
laries occurs  from  violence  or  great  internal  pressure.  In  death  from 
suffocation  the  capillaries  are  the  seat  of  hemorrhage  because  of  the 
increased  venous  pressure.  Such  capillary  hemorrhage  occurs  in  typhus, 
hemorrhagic  smallpox,  and  scarlatina.  The  state  of  the  blood  is  some- 
times the  cause  of  hemorrhage,  as  in  scurvy,  purpura,  and  other  condi- 
tions. Haemophilia  is  a  peculiar  hereditary  affection  possibly  due  to 
the  state  of  the  blood,  more  likely,  however,  due  to  the  condition  of 
the  bloodvessels. 

The  special  forms  of  hemorrhage  and  their  symptoms,  aetiology,  and 
diagnosis  will  be  considered  in  the  sections  to  which  the  names  in  the 
following  list  point : 

Bleeding  from  the  nose — epistaxis. 

Vomiting  of  blood — htematemesis. 

Bleeding  from  the  lungs — haemoptysis. 

Blood  passed  with  the  urine — hcematuria. 

Blood  passed  from  the  uterus — Menorrhagia  or  metrorrhagia. 

There  is  also  intestinal  hemorrhage — melcena. 

Hemorrhages  underneath  the  skin  are  known  as  petechia?  if  small, 
and  ecchymoses  or  suffusions  if  large. 

Hemorrhage  into  internal  organs  receives  its .  name  from  the  organ 
affected  and  is  known  as  a  parenchymatous  hemorrhage.  Apoplexy  is 
applied  to  hemorrhage  into  the  substances  of  organs,  particularly  if  it 
occurs  suddenly  and  is  localized — as  pulmonary  apoplexy,  cerebral 
apoplexy,  spinal  apoplexy.  Long  usage  has  associated  the  term  with 
hemorrhage  into  the  brain,  so  that  it  is  applied  to  that  form  alone  by 
most  writers.  Hematoma,  or  blood-tumor,  is  a  collection  of  blood  that 
has  coagulated  in  a  cavity,  organ,  or  tissue.      (See  Ear.) 

The  symptoms  of  hemorrhage  vary  in  degree  depending  upon  the 
amount  of  blood  which  escapes  from  the  vessel,  and  whether  the  hem- 
orrhage is  external  or  internal.  By  external  hemorrhage  we  mean  one 
which  is  accompanied  by  a  discharge  of  blood  visible  to  the  bystander. 
An  internal  or  concealed  hemorrhage  is  not  apparent  by  any  outward 
sign  of  blood. 

The  symptoms  by  which  external  hemorrhage  is  recognized  need  not 
be  detailed.  The  show  of  blood  in  situations  or  at  times  other  than 
normal  is  sufficient.  It  must  be  remembered  that  arterial  blood  is 
bright  red,  venous  blood  dark.  It  must  also  be  remembered  that  the 
character  of  the  blood  coming  from  internal  organs  is  modified  by  the 
secretion  of  the  affected  organ.  Thus  the  blood  from  the  stomach  is 
coagulated  and  black,  like  coffee-grounds;  blood  from  the  intestine, 
tarry.  The  general  symptoms  of  the  various  degrees  of  external 
hemorrhage  are  similar  to  the  symptoms  of  internal  hemorrhage,  which 
will  be  described  later.  Botli  vary  with  the  rapidity  of  the  flow  of 
blood.  If  the  bleeding  is  slow,  large  quantities  may  be  lost  and  more 
or  less  profound  anaemia  result.  It  is  often  more  difficult  to  deter- 
mine the  source  of  hemorrhage.  The  mode  of  recognition  of  the 
anatomical  varieties  of  hemorrhage  will  be  discussed  under  the  respec- 
tive systems  which  are  the  seat  of  the  bleeding.     Hemorrhage  may 


182  GENERAL  DIAGNOSIS. 

take  place  in  a  cavity,  as  the  stomach,  bowels,  or  bladder,  and  after 
the  blood  has  undergone  changes  it  may  cause  symptoms  of,  and  be 
discharged  as,  a  foreign  body. 

Although  internal  hemorrhage  presents  vivid  phenomena,  they  may 
not  be  characteristic,  and  its  recognition  is  often  impossible  without 
some  knowledge  of  the  history  of  the  case.  The  symptoms  are  com- 
plex. First,  we  have  pain,  a  symptom  due  to  rupture  of  a  vessel  or  to 
the  filling  of  a  tissue  with  blood.  In  the  beginning  the  pain  is  sharp, 
severe,  and  of  itself  may  cause  shock.  In  the  second  place,  the  symp- 
toms due  to  loss  of  blood  arise.  After  pain,  sudden  prostration  ensues; 
pallor  spreads  rapidly  ;  the  extremities  become  pallid  and  cold;  a  cold 
sweat  breaks  out  on  the  forehead;  the  features  become  pinched  and 
shrunken;  the  pulse  becomes  weak  and  rapid,  and  later  thready,  or 
disappears  altogether  at  the  wrist;  the  carotid  pulsates  ;  the  heart 
throbs  violently  and  a  diffused  impulse  is  seen,  at  first  vigorous,  soon 
like  a  slap  against  the  chest-wall,  and  then  it  fades  away  completely. 
On  examination  of  the  heart  and  vessels  so-called  anaemic  murmurs 
are  heard.  The  patient  is  restless,  and  sighs  and  yawns  frequently.  The 
respiration  becomes  slow  and  shallow.  Nausea  and  sometimes  vomit- 
ing may  occur.  He  may  faint  at  once  or  repeatedly,  to  be  restored 
again  and  again,  or  the  syncope  may  terminate  in  death.  In  the  inter- 
vals between  the  syncopal  attacks  the  mind  is  clear.  If,  however, 
profound  shock  is  associated  with  the  hemorrhage,  there  is  dulness  or 
stupor;  the  intellect  is  dazed;  otherwise  delirium  and  agitation  may 
be  present.  When  the  hemorrhage  is  profuse  convulsions  may  take 
place.  The  temperature  of  the  body  falls.  If  the  patient-has  fever 
at  the  time,  the  temperature  suddenly  falls  to  or  below  normal.  We 
have,  therefore,  the  following  conditions  in  hemorrhage:  syncope, 
shock,  and.  collapse.  They  may  all  be  present  in  the  same  subject, 
or  one  or  two  may  be  absent.  The  same  symptoms  may,  however, 
occur  from  other  causes,  which  must  be  excluded.  Sometimes  the 
shock  may  be  due  to  the  same  cause  as  the  hemorrhage.  The  causes  of 
shock  are  so  evident  that  they  serve  to  distinguish  it  from  the  collapse 
of  hemorrhage.  They  are  injury,  anaesthesia,  railway  accidents,  sur- 
gical operations,  perforative  peritonitis,  strangulated  hernia,  intestinal 
obstruction,  profound  mental  impression,  and  pain. 

Shock  from  hemorrhage  must  be  distinguished  from  concussion.  In 
the  latter  the  intellectual  disturbance  occurs  at  once,  and  is  more  marked 
than  the  circulatory  symptoms.  The  absence  of  the  usual  phenomena 
of  hemorrhage  serves  to  distinguish  syncope  due  to  concussion  from 
that  due  to  the  many  well-known  causes  of  fainting. 

There  are  many  forms  of  internal  hemorrhage  sufficiently  grave  to 
have  a  probably  fatal  result,  or  at  least  to  create  alarming  symptoms. 
In  the  chest,  diseases  of  the  lungs  or  the  aorta  cause  hemorrhage.  In 
concealed  pulmonary  hemorrhage  the  blood  accumulates  in  a  large 
phthisical  cavity.  When  the  aorta  or  an  aneurism  ruptures  the  blood 
may  enter  the  mediastinum  or  the  pleura.  Under  these  circumstances 
a  knowledge  of  the  previous  history  is  essential.  Careful  examination 
of  the  lungs  or  of  the  heart  or  bloodvessels  must  be  made  in  a  case 
which  presents  the  above-mentioned  symptoms  of  internal  hemorrhage. 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     183 

Internal  concealed  hemorrhage  into  organs  or  cavities  of  the  abdomen 
occurs  in  gastric,  duodenal,  or  intestinal  ulceration;  in  aneurism  or  in 
ulceration  of  large  vessels,  from  septic  inflammation  around  them.  It 
must  not  be  forgotten  that  alarming  or  fatal  internal  concealed  hemor- 
rhage may  be  due  to  haemophilia  or  purpura. 

II.   Disturbances  of  Nutrition. 

Hypertrophy  and  Atrophy  (see  Size,  and  Muscles). 

Inflammation.  Inflammation  is  a  process  largely  attended  with 
vascular  alteration,  but  also  with  disturbance  of  nutrition.  It  may  be 
acute  or  chronic.  It  is  due  to  injury,  mechanical,  physical,  chemical, 
or  vital.  The  invasion  of  micro  organisms,  or  the  irritation  of  their 
products,  is  the  most  frequent  cause  in  cases  that  come  within  the  prov- 
ince of  the  physician.  The  symptoms  are  modified  by  the  structure 
affected  and  by  the  cause  of  the  inflammation.  The  intensity  and  the 
character  also  modify  them.  The  classical  symptoms — pain,  heat,  red- 
ness, and  swelling — are  indicative  of  the  tissue-process.  In  addition 
we  have  exudation  and  alteration  of  function.  Pain  varies  in  degree 
with  the  sensibility  of  the  part.  It  is  increased  by  pressure  or  move- 
ment, and  by  the  functional  activity  of  the  affected  organ.  Heat  is 
detected  by  the  hand  or  surface -thermometer.  It  may  be  described  by 
the  patient,  in  abscess  within  the  peritoneum  or  pyosalpinx,  as  a  ball 
of  fire.  The  surface -temperature  over  an  inflamed  lung  or  pleura  is 
higher  than  over  the  healthy  side.  Redness  can  only  be  observed  in 
parts  open  to  inspection,  as  the  nasal,  oral,  faucial,  and  other  cavit:es. 
Sioelling  is  observed  with  the  redness  ;  it  is  shown  by  enlargement  of 
the  affected  organ,  if  the  latter  can  be  measured  by  palpation  or  per- 
cussion. Exudation  takes  place  from  mucous  surfaces,  into  serous 
cavities,  into  the  connective  or  any  affected  tissue,  or  into  tubes  or 
channels  (heart  and  bloodvessels,  lymphatics,  etc.).  The  symptoms 
are:  characteristic  discharges  from  mucous  surfaces;  pressure  and  phy- 
sical signs  from  accumulation  in  cavities;  symptoms  of  the  obstruction 
of  channels.  Grave  pressure-symptoms  arise  when  the  exudation 
presses  upon  the  nerves,  nerve-centres,  or  nerve  tracts  (brain,  cord, 
peripheral  nerves).  The  pressure-symptoms  are  often  more  pronounced 
than  the  inflammatory  in  simple  or  tuberculous  meningitis.  Alteration 
of  function:  The  symptoms  cannot  be  detailed  here;  each  organ  and 
structure  must  be  referred  to.  The  function  may  be  stimulated  at 
first,  but  is  soon  perverted,  or  suppressed. 

General  Symptoms.  Fever  is  the  general  expression  of  the  local 
process.  It  may  be  primary  from  reflex  irritation  of  afferent  nerves 
which  influence  the  heat-centre  and  disturb  the  thermo-taxic  mechan- 
ism. It  may  be  secondary,  the  products  of  inflammation  (pus,  toxins, 
etc.)  irritating  the  centres.  The  degree  depends  upon  the  cause. 
Active  inflammation  may  not  be  attended  by  fever.1 

Suppuration.  The  character  of  the  fever  indicates  the  variety  of 
the  inflammatory  process.  In  most  inflammations  the  fever  is  contin- 
uous.    When  there  is  suppuration,  however,  it  becomes  intermittent 

1  Musser:  "Abscess  of  Liver,"  Univ.  Med.  Magazine,  1892. 


184  GENERAL  DIAGNOSIS. 

or  remittent.  The  presence  of  suppuration  is  also  made  known  by 
hedic,  in  which  the  fever  is  attended  by  chills  and  sweats.  The  appe- 
tite is  lost  or  impaired.  There  is  also  leucocytosis.  The  urine  con- 
tains a  large  amount  of  indican.  In  obscure  inflammations  about  the 
peritoneum  the  indicanuria  points  to  a  suppuration.  While  fever- 
symptoms  in  inflammation  are  similar  save  in  degree  and  in  the  peculiar 
type  of  the  temperature-range — intermittent,  remittent,  or  continuous, 
septic  inflammations  are  attended  early  by  cerebral  symptoms,  prostra- 
tion, and  the  typhoid  state. 

As  a  corollary,  when  fever  is  present,  local  inflammation  must  be 
sought  for.  Chronic  inflammations  may  only  give  rise  to  altered  func- 
tion and  cause  exudation  (swelling,  effus'on,  etc.). 

Inflammation  of  Various  Structures.  The  symptoms  vary  according 
to  the  anatom;cal  and  physiological  peculiarities  of  the  structure. 

Inflammation  of  mucous  membranes.  Pain  is  not  excessive;  heat  is 
complained  of  (rectum) ;  redness  is  marked  and  varies  with  the  intensity 
from  bright  to  dark  red;  swelling  is  always  present.  In  narrow  chan- 
nels, as  the  nose,  or  the  gall-ducts,  it  causes  occlusion.  The  exudation 
is  at  first  mucous,  then  muco  purulent,  and  then  purulent.  Before 
exudation  there  is  a  stage  of  dryness.  The  microscopical  appearance 
of  the  exudate  varies  with  the  anatomical  character  of  the  membrane 
affected.  Its  peculiar  epithelium  is  always  present,  also  micrococci, 
pus,  red  cells  ;  from  the  lungs  or  liver,  special  crystals.  The  func- 
tions are  impaired.  Fever  is  usually  not  very  high  and  is  continuous. 
The  causes  are  direct  local  irritants  or  congestions  from  external  impres- 
sions (cold  ?). 

Inflammat'on  of  sei'ous  membranes.  Pain  is  extreme  and  may  cause 
collapse.  Heat,  sioelling,  and  redness  cannot  be  estimated.  The  sur- 
face-temperature rises.  Exudation  occurs  after  a  brief  dry  stage.  The 
cavities — pleura,  per'card'um,  peritoneum,  joints,  cerebro-sp'nal  canal 
— are  filled,  causing  mechanical  symptoms  and  phys'cal  s:gns.  Fever 
is  excessive  in  some  forms.  Function  is  impaired  or  abolished.  Gen- 
eral symptoms  are  more  pronounced.  Shock  or  collapse  is  common  in 
peritonitis.  The  affections  are  always  secondary  to  a  general  process 
(rheumatism),  to  infection,  to  disease  of  neighboring  structures,  or  to 
Bright' s  disease,  diabetes,  cancer,  scurvy,  or  other  diathetic  condition. 

Inflammation  of  muscles  (rare),  of  connective  tissue,  and  of  glands 
is  characterized  by  symptoms  common  to  the  morbid  process,  with 
alteration  of  function. 

Inflammation  of  bone  and  periosteum  presents  the  same  group  of 
symptoms.  The  pain  may  be  intense  or  of  a  dull,  aching  or  boring 
character. 

Inflammation  of  the  heart  and  vessels  is  also  attended  by  the  cardinal 
symptoms.  When  the  central  organ  is  the  seat  of  the  disease  pain  is 
not  common,  but  in  the  arteries  or  veins  it  is  of  frequent  occurrence. 
The  striking  symptom,  however,  is  the  obstruction  to  the  channels. 
It  is  characteristically  seen  in  phlebitis,  as  of  the  femoral  vein.  (Edema 
of  the  leg,  and  cyanosis,  reveal  the  obstruction.  In  the  heart  the 
acute  process  or  the  results  of  the  process  give  rise  to  all  the  symptoms 
of  obstructive  heart  disease. 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     185 

Inflammations  of  the  nerves,  the  spinal  cord,  and  the  brain  are  fol- 
lowed more  strikingly  by  pressure-symptoms  and  by  the  symptoms  of 
degenerations  secondary  to  the  inflammatory  process.  Hence,  while 
pain  and  tenderness  are  present  in  the  exposed  nerves,  increased  irrita- 
bility, then  abeyance,  perversion,  or  abolition  of  function  are  the  prin- 
cipal signs  of  inflammation  of  these  regions. 

Inflammation  of  internal  organs,  lung,  liver,  kidneys,  and  pancreas  is 
made  known  by  pain  (minimum  amount)  and  swelling  (enlargement  of 
liver),  and  by  change  in  the  function,  indicated  by  modifications  of  the 
respective  secretions  as  well  as  by  functional  and  physiological  symptoms. 

Local  Death,  Necrosis,  and  Gangrene.  If  nutrition  is  not 
complete,  the  life  of  the  cell  is  endangered.  This  process  is  known 
as  necrosis  or  gangrene.  The  nutrition  is  annulled:  1.  By  stoppage 
of  the  circulation ;  2.  By  the  direct  action  of  an  irritant  which  destroys 
the  cells;  3.  By  abnormal  temperature.  A  combination  of  the  three 
causes  quickly  produces  gangrene.  Stoppage  of  the  circulation  may 
be  due  to  an  embolus  or  thrombus,  or  to  stagnation  by  pressure,  or  to 
capillary  stasis  alone.  Sloughing  and  u  bedsores  "  ensue  in  the  latter 
instance  ;  gangrenous  eschars  in  the  former.  The  cells  are  destroyed 
by  corrosives  and  caustics,  by  heat  and  cold,  by  bacteria.  Where 
decomposition  takes  place,  as  in  retained  and  infiltrating  urine,  cell- 
destruction  and  sloughing  ensue.  All  pathogenic  bacteria  cause  ne- 
crosis to  greater  or  less  degree.  Frost-bite  and  burn  illustrate  the 
destructive  power  of  abnormal  temperature. 

Nerve-lesions,  trophic  disorders,  produce  necrosis.  We  have,  allied 
to  bedsores  and  known  as  decubitus,  a  form  of  necrosis  in  spinal-cord 
diseases.  The  sloughing  is  extensive  and  rapid.  Trophic  disorders 
cause  paralytic  hypersemia,  and  hence  necrosis. 

It  must  not  be  forgotten  that  debility,  cachexia,  and  feeble  circula- 
tion play  a  great  part  in  assisting  the  local  changes. 

Gangrene  of  internal  structures  concerns  us.  This  form  is  nearly 
always  due  to  stoppage  of  the  circulation.  It  is  seen  in  constriction 
of  the  intestine,  from  hernia,  or  obstruction.  It  occurs  in  phthisis  from 
thrombi.  Clinically,  we  see  it  frequently  in  diabetes.  The  lung,  the 
brain,  the  intestines,  are  most  frequently  affected. 

The  symptoms  of  necrosis  or  gangrene  are  modified  by  the  tissue 
involved,  the  function  interfered  with.  If  external,  the  decomposing 
structures  emit  a  foul  odor,  there  is  rapid  prostration  and  development 
of  the  typhoid  state.  Fever  ensues  from  intoxication  by  decomposing 
substances — sapreemia.  Often  the  symptoms  are  latent.  A  man  aged 
sixty,  in  my  ward,  was  about  all  the  time.  He  died  suddenly  of  pul- 
monary hemorrhage,  the  result  of  gangrenous  ulceration  of  a  large 
vessel;  at  the  autopsy  gangrene  of  the  lung  was  found.  The  only 
symptom  was  the  characteristic  odor.  In  the  course  of  inflammatory 
processes  the  onset  of  gangrene  is  frequently  attended  by  the  cessation 
of  pain,  the  peculiar  odor  when  it  communicates  with  the  exterior, 
and  the  development  of  exhaustion  and  the  typhoid  state.  The  char- 
acter of  the  discharge  points  to  gangrene.  When  the  lungs  are  affected 
the  expectoration  is  like  prune-juice;  when  the  bowels,  the  discharge 
is  dark  and  putrid. 


186  GENERAL  DIAGNOSIS. 

Fever  is  a  morbid  process,  with  the  cause  and  symptomatology  of 
which  the  student  must  be  familiar.  It  has  been  fully  treated  in  a 
previous  chapter  (see  Fever  and  Infectious  Diseases). 

The  Degenerations.  The  symptomatology  varies  with  the  form 
of  degeneration  and  the  organs  affected.  The  prostration  of  the  gen- 
eral economy  is  due  to  the  same  cause  as  the  degenerations  themselves. 

Albuminous  degeneration  occurs  in  fever,  and  causes  the  weak  heart 
and  defective  gland  action.  The  weak  heart  of  the  convalescent  period 
in  diphtheria  and  other  infective  diseases  is  well  known. 

Fatty  Degeneration  and  Infiltration.  In  fatty  degenera- 
tion there  is  cell-destruction.  The  brain,  the  heart,  the  kidneys  in 
Bright' s  disease,  the  liver,  all  undergo  degeneration.  It  may  be  due 
to  phosphorus-poisoning  or  to  snake-bite.  It  is  seen  in  acute  yellow 
atrophy  of  the  liver.  It  is  caused  by  other  toxic  agents.  Fatty  infiltra- 
tion or  lipomatosis  is  seen  in  the  "  fat';  heart  of  brewers,  the  enlarged 
liver,  the  excess  of  fat  iu  the  abdomen,  etc.  The  affected  organs  are 
enlarged,  but  they  are  functionally  weak.  Fatty  infiltration  of  organs 
is  recognized  by  its  serological  associations.  In  alcoholic  subjects  of 
sedentary  habits,  in  subjects  who  eat  an  excess  of  fatty  foods,  in  over- 
fed and  pampered  children,  and  in  tuberculosis  it  is  commonly  seen. 
In  fatty  infiltration  the  cells  are  not  destroyed.  If  with  the  above 
conditions  the  liver  is  enlarged  or  the  heart  weak,  or  both,  we  may 
expect  to  find  fatty  infiltration.  There  is  enlargement  of  the  affected 
organ,  which  is  painless,  smooth,  not  usually  soft  on  palpation.  The 
condition  occurs  at  any  age,  but  usually  in  later  life.  Emaciation 
may  not  be  present.      Lithsemia  is  common  in  fatty  infiltration. 

Amyloid  Degeneration.  This  is  rarely  confined  to  one  organ 
of  the  body.  The  causes  are  syphilis,  malaria,  tuberculosis,  and  pro- 
longed suppuration.  The  liver  and  spleen  are  enlarged,  hard,  smooth, 
and  painless.  There  are  great  pallor,  and  oedema  of  the  feet  and  face. 
There  is  anosmia,  but  no  fever.  The  kidneys  are  affected,  hence  'poly- 
uria and  low  specific  gravity  of  the  urine  ;  a  few.  casts  are  found. 
The  bowels  are  likely  to  be  loose  because  the  process  has  involved 
the  intestine.  It  occurs  at  any  age.  The  diagnosis  rests  on  the  pres- 
ence of  a  cause,  the  painless  enlargement  of  organs,  the  pallor,  and  the 
polyuria. 

Fibroid  Degeneration.  This  is  not  so  much  a  degeneration  as 
an  overgrowth  of  connective  tissue  with  coincident  primary  or  secondary 
atrophy  of  the  parenchyma.  The  function  of  the  organ  is  impaired 
or  abolished.  Increase  of  connective  tissue  in  the  nerve-structures  is 
known  as  sclerosis,  in  the  liver  or  kidney  as  cirrhosis.  In  the  artery  it 
leads  to  the  changes  known  as  endarteritis.  Whatever  the_  pathology 
may  be,  whether  atrophy  of  cell-elements  of  the  affected  structure  be 
primary  or  secondary,  the  condition  is  productive  of  serious,  even  grave 
consequences.  It  is  part  of  the  senile-  process.  It  leads  to  the  mani- 
fold symptoms  of  endarteritis  ;  it  is  the  cause  of  many  nervous  affec- 
tions which  will  be  discussed  in  their  proper  sections. 

The  varied  phases  of  so-called  interstitial  nephritis  are  due  to  the 
fibroid  changes  primarily  in  the  kidneys,  and  secondarily  in  the  arterial 
system.      In  the  lungs  it  attends  emphysema,  or  may  even  be  produc- 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     187 

tive  of  that  condition.  The  fibroid  heart  is  another  manifestation  of 
the  same  process.  The  tubes  and  channels  are  closed  by  the  same 
process  as  in  fibrous  stricture  of  the  duodenum.  Wherever  situated 
its  development  means  gradual  abolition  of  function. 

Mucous  Degeneration.  This  form  of  degeneration  is  seen  in 
myxoedema.  The  albuminous  intercellular  substance  is  replaced  in  the 
connective  tissue  by  mucin. 

Pigmentary,  calcareous,  and  colloid  degenerations  are  local  morbid 
processes  without  other  symptoms  than  those  of  the  primary  affection. 

Tumors  and  New  Growths.  Tumors,  other  than  cancer  or  sar- 
coma, produce  only  mechanical  symptoms  and  must  be  considered  in 
their  special  section.  The  mechanical  symptoms  are  due  :  1.  To  the 
tumor  (foreign  body).  2.  To  obstruction  of  any  channel  in  near  rela- 
tion. Cancel'  and  sarcoma  are  accountable  for  a  group  of  symptoms 
to  which  the  term  cachexia  has  been  applied. 

It  is  true  tumors  produce  local  symptoms.  This  is  most  striking  in 
structures  which  must  necessarily  be  destroyed  as  the  growth  increases 
in  size,  as  in  the  brain  or  spinal  cord,  or  where  tubes  or  channels  are 
closed,  as  in  cancer  of  the  stomach  or  oesophagus.  (See  Special  Diag- 
nosis.) 

Local  symptoms  may  precede  the  general  symptoms;  on  the  other 
hand,  general  symptoms  may  arise  for  which  no  local  cause  can  be 
assigned.  The  local  symptoms  of  cancer  are  variable  and  depend  upon 
the  anatomical  nature  and  physiological  offices  of  the  organ  affected, 
and  upon  its  anatomical  relation  to  surrounding  organs.  This  class  of 
symptoms  will  be  referred  to  in  the  section  on  special  diagnosis.  Suffice 
it  to  say  they  cause  gradual  abolition  of  the  function  of  the  organ,  or 
closure  of  the  channels  in  connection  with  it,  as  the  intestinal  canal, 
the  pharynx,  or  the  hepatic  ducts.  A  few  symptoms  belong  to  the 
cancerous  process  wherever  situated.  They  may  or  may  not  all  be 
present;  in  the  large  majority  of  cases  one  or  more  are  Wanting  ;  they 
should  always  be  sought  for  in  order  to  confirm  a  diagnosis  of  cancer. 
These  symptoms  are  : 

1.  Pain,  recognized  by  peculiar  characteristics  in  most  cases:  (a)  It 
is  sharp  and  lancinating;  (6)  it  is  paroxysmal;  (c)  it  is  increased  by 
irritation,  as  food  when  the  stomach  is  affected;  (d)  it  is  increased  by 
functional  activity,  as  speaking  or  swallowing  in  carcinoma  of  the 
larynx  or  pharynx.  («)  At  the  outlet  of  canals,  as  fhe  bladder  or 
rectum,  it  gives  rise  to  tenesmus. 

2.  Hemorrhage.  If  the  malignant  mass  is  in  communication  with 
the  exterior,  the  blood  may  be  discharged  per  vias  naturales.  In  malig- 
nant disease  of  the  upper  air-passages  or  the  lungs  hemorrhage  is  likely 
to  occur.  It  is  c  immon  in  gastric  carcinoma  as  well  as  in  uterine  cancer. 
If  the  organs  do  not  communicate  with  the  exterior,  and  the  lesion 
gives  rise  to  exudations  or  transudations,  the  Litter  are  frequently 
bloody,  as  in  carcinoma  of  the  pleura  or  peritoneum. 

3.  Abnormal  Discharge.  This  occurs  especially  in  cancer  of  the 
hollow  viscera  and  of  the  canal-structures.  The  discharge  is  the  result 
of  inflammation,  suppuration,  and  necrosis,  and  particularly  microbic 
inflammation.      It  is  recognized  by  its  more  or  less  blood//  character 


188  GENERAL  DIAGNOSIS. 

and  by  its  odor,  which  is  peculiar.  It  is  most  offensive  and  penetrat- 
ing, and,  particularly  in  uterine  cancer,  is  almost  pathognomonic. 
Even  the  utmost  cleanliness  will  not  obviate  it. 

4.  Tumor.  It  may  be  readily  detected  or  elude  all  search.  Some 
swelling  is  certainly  present.  It  is  discovered  by  external  examination, 
by  the  objective  physical  signs  of  enlargement  or  change  of  contour  of 
the  affected  organ. 

5.  Foreign  body.  The  growth  gives  rise  to  symptoms  similar  to 
those  present  when  a  foreign  body  is  fixed  in  any  portion  of  the  hollow 
viscera,  as  the  respiratory  tract,  the  gastro  intestinal,  including  the 
hepatic  and  the  genito -urinary  tract,  a.  Through  reflex  influence  an 
attempt  is  made  to  remove  it,  hence  cough,  vomiting,  diarrhoea  with 
tenesmus,  repeated  and  painful  micturition  with  tenesmus,  etc.,  the 
particular  symptoms  varying  with  the  organ  affected,  b.  Obstruction 
of  the  channels,  with  all  the  accompanying  symptoms,  depending  upon 
the  location  of  the  growth. 

6.  Temperature.  A  morbid  process  is  often  recognized  by  its  nega- 
tive symptoms,  if  the  term  may  be  used.  Thus,  fever  is  absent  or  the 
temperature  is  even  subnormal  in  carcinoma. 

7.  The  Cancerous  Cachexia.  Wherever  situated  the  disease  is  sooner 
or  later  attended  by  extreme  general  symptoms  which  are,  in  a  measure, 
striking.  It  is  to  be  admitted  that  cases  of  carcinoma  often  occur 
without  marked  cachexia,  a.  One  symptom  may  always  be  looked 
for;  it  is  emaciation.  It  may  be  rapid  or  gradual  and  extend  over  one 
to  two  years;  toward  the  end  it  is  always  rapid.  Ultimately  if  the 
patient  does  not  succumb  to  other  conditions,  it  presents  an  extreme 
picture.  The  eyes  are  sunken,  all  normal  accumulations  of  fat  disap- 
pear. The  fat  in  the  rectal  fossa?  disappears,  causing  deep  depression 
of  the  rectum.  The  abdomen  is  retracted.  The  appearances  are  most 
striking  in  cancer  of  the  oesophagus,  b.  Pallor  (see  Faeces);  this  may 
be  present.  c.  Ancemia,  with  breathlessness,  palpitation,  vertigo. 
d.  Exhaustion.  This  with  accompanying  emaciation  is  progressive,  and 
may  be  the  first  symptom.  Progressive  weakness  is  often  seen  without 
fever  or  local  disorder  to  account  for  it.  Toward  the  end  it  becomes  so 
extreme  as  to  forbid  exertion,  e.  Malnutrition.  Evidences  of  malnutri- 
tion appear;  the  skin  is  hard  and  dry;  its  elasticity  is  impaired  and  it 
becomes  the  field  for  parasitic  invasion.  Tinea  and  other  parasites 
may  flourish.  Bacteria  invade  the  susceptible  areas,  and  boils  make 
their  appearance.  The  secretions  are  perverted.  In  the  mouth  ulcers 
develop  ;  the  fungi  of  this  situation  (the  throat,  etc.)  become  more  ac- 
tive; the  gums  are  inflamed.  In  the  later  stages  the  "  typhoid  state" 
(see  Fever)  may  ensue.  If  the  gastro-intestinal  tract  is  invaded,  symp- 
toms of  acute  intoxication  may  arise. 

8.  Metastasis.  We  are  often  aided  by  the  occurrence  of  this  event, 
particularly  by  involvement  of  the  glands.  In  gastric  carcinoma  sec- 
ondary hepatic  disea<e  or  enlarged  glands  above  the  left  clavicle  are 
found;  in  rectal  carcinoma,  secondary  hepatic  cancer.  In  many 
instances  the  pre-ence  of  cancer  is  revealed  by  the  metastasis,  even 
when  the  primary  growth  cannot  be  recognized. 

The  diagnosis  rests  upon  the  above  conditions.     In  obscure  cases 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     189 

the  age,  the  sex,  the  associate  pathologic  conditions,  the  duration  of 
the  disease  become  important  factors  in  the  diagnosis.  Cancer  usually 
occurs  after  forty,  or,  some  authorities  say,  after  fifty  years  of  age. 
The  female  sex  is  most  frequently  affected.  It  may  be  as.-ociated  with 
a  history  of  previous  lesion  or  irritation,  as  ulcer  in  vaginal,  gastric, 
or  rectal  cancer;  the  irritation  of  teeth  or  a  pipe  in  labial  and  lingual 
cancer;  of  gall  stone  in  cancer  of  the  bile-ducts;  of  renal  or  vi>ceral 
calculus  in  disease  in  that  situation.  A  disease  of  grave  and  malignant 
character,  the  duration  of  which  is  over  eighteen  months  or  two  years, 
is  not,  in  all  probability,  cancer. 

Mordid,  Processes  in  Tubes  or  Channels.  The  effects  produced 
by  obstructions. 

When  tubes  or  channels  are  the  seat  of  disease  symptoms  arise  apart 
from  the  special  morbid  process,  which  are  due  to  obstruction  and  are 
common  to  all  tubes  or  channels.  The  symptoms  of  obstruction  of 
the  bloodvessels  and  lymph-channels — cyanosis,  oedema,  gangrene 
(thrombosis  and  embolism) — have  been  described.  But  in  addition  we 
have  hypertrophy,  a  secondary  condition,  not  referred  to  above,  which, 
nevertheless,  follows  obstruction  of  any  channel.  In  the  cases  of  vas- 
cular obstruction  the  hypertrophy  is  seen  in  the  heart  and  the  arteries 
(see  Diseases  of  the  Heart). 

In  obstruction,  therefore,  of  tubes  or  channels  we  have  to  a  greater 
or  less  extent  (1)  hypertrophy  behind  obstruction  ;  (2)  diminution 
of  the  normal  flow  of  fluid  and  consequent  accumulation  of  material 
which  normally  passes  through  the  channels;  (3)  atrophy  and  cessation 
of  functional  activity  beyond  the  point  of  obstruction;  (4)  dilatation 
of  the  primary  hypertrophy;  (5)  degeneration,  ulceration,  low-grade 
inflammation  (bacterial),  secondary  rupture  of  the  affected  viscera. 
The  morbid  anatomist  can  readily  point  out  the  examples  of  the  mor- 
bid changes  sequential  to  obstruction.  Thus  in  cancer  of  the  oesoph- 
agus there  are  hypertrophy  of  the  muscular  coats,  regurgitation  of  food, 
atrophy  of  the  stomach,  dilatation  with  accumulation  of  food,  secre- 
tions from  the  glands  of  the  oesophageal  mucous  membrane,  secondary 
ulceration,  rupture  into  the  lungs,  with  gangrene  or  pneumonia,  In 
obstruction  at  the  pylorus  there  are  (1)  hypertrophy;  (2)  accumulation; 
(3)  intestinal  atrophy;  (4)  dilatation  of  the  stomach,  with  its  train  of 
symptoms.  In  obstruction  of  the  biliary  channels,  or  the  bladder,  or 
ureters,  the  same  secondary  conditions  arise  plus  obsi  ruction  to  the  flow 
of  bile  or  urine.  Secondary  symptoms  arise  from  accumulation  of  the 
non-escaping  fluids.  Subjective  symptoms,  it  may  be  said,  are  not 
marked;  there  are  pain  and  difficulty  in  the  performance  of  the  usual 
functions.  It  need  scarcely  be  said  that  the  obstruction  sometimes 
gives  rise  to  symptoms  which  are  due  to  the  abnormal  obstructing 
material  which  acts  as  a  foreign  body.  The  symptoms  are  reflex  and 
depend  entirely  upon  the  seat  of  the  foreign  body. 

The  causes  of  obstruction  in  whatsoever  channel  situated  arc,  first, 
pressure  from  disease  outside  (growths,  hernia);  second,  disease  of  the 
walls,  with  contraction;  third,  occlusion  by  a  foreign  body,  as  gall- 
stone, renal  calculus,  worms,  or  other  material  according  to  the  channel 


190  GENERAL  DIAGNOSIS. 

obstructed.  The  symptoms  are  most  marked  when  the  obstruction  is 
due  to  disease  outside  the  walls  or  to  obstruction  by  occlusion  within 
the  walls. 

In  all  cases  of  obstruction,  nasal,  faucial,  laryngeal,  bronchial,  oeso- 
phageal, gastro-intestinal,  biliary,  renal,  .or  pancreatic,  look  for  the 
symptoms  of  the  secondary  morbid  change.  Each  form  of  obstruction 
will  be  specially  considered  elsewhere  (see  Special  Diagnosis). 

The  Bloodvessels.  Blood-pressure.  It  must  not  be  forgotten 
that  the  bloodvessels  are  in  a  measure  distinct  from  other  tubes,  although 
subject  to  the  same  laws,  physiological  and  pathological.  They  contain 
fluids,  and  have  a  continuous  function  by  which  the  fluids  are  propelled. 
They  are  subject  to  the  laws  that  govern  the  flow  of  fluids  under  all 
circumstances  in  nature.  Any  derangement  or  disease  will  effect  changes 
which  are  explainable  by  hydrostatic  or  hydroclynamic  laws.  Fluids 
within  vessels  exert  pressure.  Pressure  produced  by  weight  of  the 
fluid  is  known  as  the  hydrostatic  pressure;  that  produced  by  the  flow 
is  known  as  the  hydroclynamic  pressure.  Pressure  can  be  gauged  by 
proper  instruments.  In  the  case  of  fluid  in  the  bloodvessels  it  is 
called  the  blood-pressure.  The  blood-pressure  is  estimated  at  the 
pulse  by  the  educated  finger  and  by  the  sphygmograph.  A  certain 
definite  pressure  is  always  present  in  health.  It  is  subject  to  slight 
fluctuations,  but  tracings  with  a  sphygmograph  follow  a  definite  course. 
In  the  description  of  the  pulse  modifications  of  blood-pressure  will  be 
given  in  detail;  it  is  sufficient  here  to  say  a  few  words  regarding  hydro- 
static and  hydroclynamic  pressure. 

Hydrostatic  pressure  is  modified  by  the  weight  of  the  fluid.  It  is  of 
pathological  importance  in  the  veins  only,  and  especially  in  those  of 
the  lower  limbs.  When  the  pressure  is  increased  the  increased  wi  ight 
of  the  blood-column  causes  increased  bulk  and  over-distentiun,  as  in 
varicose  veins,  unless  the  support  to  the  blood-column  is  increased. 
Inflammations  of  the  lower  limbs  are  attended  by  venous  accumulation 
and  followed  by  ulceration.  For  this  reason  dropsies  arise  more 
readily  in  these  portions.  The  common  occurrence  of  gout  in  the  feet 
may  be  due  to  slow  circulation. 

Hydfodynamio  pressure  is  variable.  Its  changes  indicate  increase  or 
diminution  of  blood-pressure.  The  bloodvessels  are  resisting  elastic 
tubes;  the  resistance  is  always  equal  to  the  pressure  within,  hence 
blood-pressure  and  arterial  tension  are  equivalent  terms.  AYe  speak  of 
increased  or  diminished  pressure,  or  correspondingly  of  high  or  low 
tension.  Now  the  hydroclynamic  or  blood-pressure  depends  upon,  1, 
variations  in  the  volume  of  blood;  2,  variations  in  the  capacity  of  the 
vascular  system;  3,  facility  of  the  capillary  circulation;  4,  the  force  of 
the  heart.     The  tension  of  the  artery  depends  upon  the  same  conditions. 

1.  Variations  in  the  volume  of  the  blood,  a.  Volume  increased. 
Causes  :  absorption  of  fluid  after  meals  or  drinking  to  excess.  Result : 
increased  blood-pressure  and  increased  tension.  Controlled  in  health 
by  action  of  the  vasomotors  relaxing  the  vessels,  and  by  enlargement 
of  the  veins.  b.  Volume  diminished.  Cause  :  hemorrhage,  serous 
purging.      Result :  diminished  blood-j)ressure,  lowered  tension.      Con- 


THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     191 

trolled  in  health  by  contraction  of  arteries  through  vasomotor  nerves. 
In  hemorrhage  the  loss  of  blood  produces  anaemia.  The  latter  is  a 
stimulant  to  the  vasomotor  centre  in  the  medulla,  and  produces  con- 
traction of  peripheral  arteries  and  high  tension. 

2.  Variations  in  the  capacity  of  the  vessels,  a.  Diminution  of  the 
capacity  of  the  blood-channels  (volume  of  blood  not  lessened).  Cause  : 
cutting  off  of  a  vascular  area  by  ligation  or  obstruction,  by  narrowing 
the  calibre  of  the  wall  as  in  arterial  spasm  or  endarteritis,  by  disease 
of  the  kidneys  contracting  the  lessening  channels  in  the  aortic  circuit, 
or  disease  of  the  aorta  causing  obstruction  to  the  outflow  of  blood. 
Result :  increased  pressure,  high  tension.  Controlled  by  normal  reg- 
ulating vasomotor  apparatus,  or  by  diminution  of  the  volume  of  blood. 
b.  Increase  of  capacity  of  blood-channels.  Cause  :  relaxation  of  mus- 
cular coats  of  vessels.  Result :  diminished  blood-pressure,  lowered 
arterial  tension.  Controlled  by  contraction  of  vessels  or  increase  in 
amount  of  blood.  In  shock,  the  vasomotor  sympathetic  system  of  the 
splanchnic  arteries  is  so  disturbed  that  the  arteries  are  dilated  and  all 
the  blood  is  sent  into  the  abdominal  vessels  (fall  of  pressure). 

Mode  of  action  of  the  vasomotor  apparatus.  Centres  in  the  medulla, 
in  the  spinal  cord,  and  loyally  in  the  sympathetic  ganglia  of  different 
part-,  control  the  vasomotor  nerves,  which  influence  hydrodynamic 
pressure.  1.  If  the  centres  are  stimulated,  tonic  contraction  of  the 
vessels  is  produced.  This  may  be  general  or  local.  Increased  pres- 
sure or  heightened  tension  is  the  result.  It  may  be  reflex  from  the 
periphery,  or  due  to  some  state  of  the  blood.  2.  If  the  centres  are 
paralyzed,  or  inhibited,  or  cut  off  from  the  arteries,  the  latter  become 
relaxed  (dilated).  The  pressure  is  lowered,  the  tension  is  less.  IShock, 
pain,  certain  drags,  reflexes  (probably)  produce  inhibition. 

3.  Facility  of  capillary  circulation.  Obstruction  to  outflow  of  blood 
from  capillaries  into  the  veins  increases  blood-pressure.  Cause  :  the 
same  as  when  arteries  contract.  Result :  increased  blood-pressure, 
high  tension.  Regulated  in  the  same  manner  as  arteries.  Relaxed 
capillaries  produce  opposite  conditions. 

4.  The  force  of  the  heart,  a.  Heart' s  action  (left  ventricle)  increased. 
Cause  :  hypertrophy,  palpitation.  Hence  the  greater  force  of  blood- 
impact,  greater  resistance  by  arteries.  The  tonic  resistance  narrows 
the  calibre  of  the  vessels.  Result. :  increased  pressure,  higher  tension. 
b.  Heart's  action  weakened.  Hence,  less  force  of  blood,  less  resistance. 
Result :  lessened  pressure,  low  tension. 

The  recognition  of  variations  in  tension.      (See  Pulse.) 

1.  High  arterial  pressure  or  tension.  By  (a)  incompressibility  and 
tension  of  the  arteries  ;  (6)  accentuation  of  the  aortic  second  sound  ; 
(c)  prolongation  of  the  left  ventricle  first  sound;  (<7)  increased  flow  of 
urine,  pale  and  watery;  (e)  characteristic  pulse-tracing  by  sphygmo- 
graph.  If  the  high  tension  is  permanent,  (/)  hypertrophy  of  the  heart; 
(g)  atheroma,  more  or  less. 

2.  Low  arterial  pressure  or  tension.  By  (a)  soft,  compressible, 
often  dicrotic  pulse;  (b)  enfeebled  sounds,  aortic  second  and  left  ven- 
tricle; (e)  scanty,  high-colored  urine;  (c/)  special  pulse-tracing.  If 
permanent,  stases,  congestions,  cyanosis,  with  general  weakness  and 
impaired  nutrition. 


PART    II. 

SPECIAL    DIAGNOSIS. 


CHAPTER   I. 

DISEASES  OF  THE  NOSE  AND  LARYNX. 
The  Nose. 

The  symptoms  of  disease  of  the  nose  result  from  the  function  and 
the  structure  of  the  organ  and  the  morbid  process.  Physiologic  symp- 
toms :  The  sense  of  smell  may  be  impaired,  and  symptoms  of  more 
or  less  obstruction  may  occur.  Obstruction  causes  more  or  less 
marked  retention  of  secretions.  These  secretions  are  exposed  to  in- 
fection from  without  by  bacteria.  Putrefaction  and  fermentation 
set  in  and  give  rise  to  offensive  odors.  More  serious  is  the  effect 
of  the  obstruction  on  the  rest  of  the  respiratory  tract.  On  account 
of  it  the  air  must  pass  through  the  mouth,  and  the  patient  becomes 
a  mouth-breather.  The  appearance  of  the  face  is  altered;  the  voice 
changes,  snoring  is  common,  mastication  is  interfered  with,  and 
there  is  a  diminution  in  the  amount  of  air  passing  to  the  lungs. 
As  a  result  a  vacuum  is  created  which  is  compensated  by  external 
pressure.  In  children  the  result  is  marked  deformity  of  the  chest, 
leading  to  the  development  of  the  ' '  chicken  breast. ' '  The  sides  of  the 
sternum  are  depressed,  the  transverse  groove  is  increased,  the  sternum 
itself  is  projected  forward.  The  general  symptoms  that  accompany 
such  interference  with  breathing  will  be  referred  to  again. 

Symptoms  due  to  the  Anatomical  Structure.  The  nose  is  an  open 
space  or  series  of  air-spaces  lined  with  mucous  membrane.  The  mucous 
membrane  is  the  frequent  seat  of  infectious  inflammation,  as  in  hay 
fever,  influenza,  and  measles.  Most  of  the  nasal  symptoms  are  due  to 
disease  of  the  mucous  membrane.  The  membrane  is  subject  to  affec- 
tions that  are  common  to  all  mucous  membranes,  and  the  subjective  and 
objective  symptoms  are  similar  to  those  that  arise  in  other  organs,  mod- 
ified by  the  function  and  anatomical  arrangement. 

The  abundance  of  bloodvessels  and  glands  is  the  cause  of  one  of  the 
symptoms,  namely,  the  discharge.  Moreover,  the  difficulty  of  removing 
the  discharge  from  the  various  cavities  in  the  nose  in  which  they  are 
pent  up  leads  to  putrefaction  and  odor.  Because  the  air  is  constantly 
passing  over  the  parts,  discharges  are  very  liable  to  become  dry,  and 
hence  crusts  and  scabs  form.  Again,  the  vascularity  of  the  structures 
of  the  nose  is  the  cause  of  development  of  symptoms.      The  blood- 

13 


194  SPECIAL  DIAGNOSIS. 

vessels  are  richly  supplied  with  nerves,  which  cause  them  to  contract 
or  dilate  on  comparatively  slight  provocation,  by  reflex  action.  Chilli- 
ness of  the  body,  or  of  local  areas  of  the  body,  chilling  of  the  extrem- 
ities, and  other  peripheral  impressions,  are  followed  by  congestion  of 
the  nasal  mucous  membrane,  which  may  go  on  to  inflammation.  The 
vascularity  predisposes  to  hemorrhage. 

The  nose  is  richly  supplied  with  nerves  (in  addition  to  the  olfactory 
nerve)  which  are  susceptible  to  various  irritations  or  impressions — 
impressions  made  by  the  air  laden  with  unusual  material,  as  fumes  of 
a  chemical  nature,  emanations  from  animals,  or  irritating  plants,  and 
certain  materials  not  yet  isolated,  which  are  decidedly  irritating.  There 
is  often  local  irritation  from  polyps  and  adenoid  growths,  and  foreign 
bodies,  or  enlarged  bone.  The  nerves  are  connected  by  a  mechauism 
directly  with  the  centres  in  the  medulla,  this  is  particularly  true  of 
the  pneumogastric.  The  effect  of  peripheral  nasal  irritation  may 
be  felt  reflexly  in  the  area  of  distribution  of  that  nerve;  hence 
an  unpleasant  odor  may  bring  on  sudden  nausea  or  vomiting.  But  of 
more  striking  and  frequent  pathological  significance  is  the  occurrence 
of  asthma,  or  sudden  dyspnoea,  from  reflex  excitation  of  the  pulmonary 
division  of  the  pneumogastric  nerve. 

Morbid  processes  in  the  nose  are  symptomatic  of  some  general  affec- 
tions. The  occurrence  of  asthma,  or  of  deformity  of  the  chest  and 
general  ill-development,  has  been  spoken  of.  Acute  inflammations 
are  significant  of  the  exanthematous  diseases,  particularly  measles.  An 
acute  inflammation  (as  pointed  out  by  Meigs)  with  great  obstruction  of 
the  nares  and  an  abundant,  puriform  discharge,  is  a  complication  or 
symptom  of  Bright' s  disease  that  may  portend  the  onset  of  uraemia. 
Chronic  inflammations  may  be  due  to  syphilis  or  other  chronic  infection. 

The  Data  Obtained  by  Inquiry. 

The  Subjective  Symptoms.  These  are  often  accompanied  by 
extreme  distress,  but  do  not  lead  to  a  fatal  termination.  The  general 
subjective  symptoms  are  allied  to  those  of  inflammation  of  other 
mucous  membranes.  Lassitude  occurs  when  there  is  fever.  It  is  a 
frequent  precursor  of  rhinitis,  and  is  pronounced  in  croupous  and  diph- 
theritic rhinitis;  extreme  prostration  may  attend  the  latter.  Chilliness 
following  the  lassitude,  or  rigor,  may  occur  in  the  same  class  of  cases. 
If  distinct  rigors  occur,  an  abscess  in  one  of  the  cavities  may  be  sus- 
pected, if  the  subjective  and  objective  symptoms  point  to  it;  or  glanders 
may  be  present 

Fever.  This  occurs  in  the  inflammations;  it  is  never  marked,  and  is 
not  of  diagnostic  significance.  It  is  more  severe  in  glanders  than  in 
any  other  affection  of  the  nares.  It  is  of  low  type  in  diphtheria,  and 
of  hectic  character  when  there  is  abscess.  High  fever  associated  with 
inflammations  of  the  nose  points  to  influenza  or  one  of  the  exanthemata 
as  the  primary  cause  of  the  rhinitis.  Foreign  bodies  in  the  nose  may 
cause  fever  of  an  inflammatory  character. 

Local  Subjective  Symptoms.  Pain,  varying  in  degree,  occurs 
in  all  acute  affections  of  the  nose.      Its  seat  and  character  are  of  some 


DISEASES  OF  THE  NOSE  AND  LARYNX.  195 

diagnostic  significance.  A  smarting  or  burning  pain  at  the  root  of  the 
nose  accompanies  acute  rhinitis  and  attends  post-nasal  catarrh.  The 
pain  is  diffuse  and  indefinite  in  dry  catarrh  and  in  diphtheria.  The 
most  severe  pain  occurs  when  foreign  bodies  are  present  in  the  nose  and 
in  cases  of  glanders  and  primary  syphilis.  Foreign  bodies  of  a  vege- 
table nature  by  swelling  and  germinating  induce  pain,  which  increases 
gradually  in  intensity. 

Pain  over  the  Frontal  Sinus.  Pain  over  the  sinus  when  it  is  the  seat 
of  inflammation  is  more  severe  than  in  the  nose  when  it  is  inflamed. 
It  is  sometimes  so  intense  and  agonizing  as  to  cause  serious  general 
effects.  Pain  may  also  be  located  in  the  cheek  on  account  of  inflam- 
mation or  other  disease  of  the  antrum.  In  disease  of  the  nose,  if  the 
pain  radiates  to  the  ear,  the  Eustachian  tubes  are  probably  involved. 

Disturbance  of  the  Sense  of  Smelt.  Anosmia  and  Parosmia.  Loss  of 
smelt,  or  anosmia,  occurs  to  a  moderate  degree  in  all  the  inflammatory 
and  obstructive  diseases  of  the  nose.  The  intensity  depends  upon  the 
degree  of  change  in  the  mucous  membrane.  It  may  also  be  due  to 
disease  of  the  nerves  or  the  olfactory  centre  in  the  brain.  Parosmia 
is  the  perception  of  abnormal  odors,  and  may  be  a  neurosis  or  psychical 
difficulty  entirely,  and  hence  purely  subjective,  or  there  may  be  inability 
to  distinguish  an  odor  when  presented  to  the  nostril.  All  odors  may 
appear  the  same,  or  agreeable  odors  may  seem  to  the  patient  very  dis- 
agreeable. In  addition  the  patient  may  complain  of  the  perception  of 
an  odor  in  connection  with  the  nasal  disease  with  which  he  is  affected. 
Parosmia  is  due  to  an  involvement  of  the  olfactory  nerves. 

A  sense  of  dryness  is  a  symptom  of  which  the  patient  frequently 
complains,  particularly  in  the  early  stages  of  acute  rhinitis  and  through- 
out the  entire  course  of  dry  catarrh,  or  atrophic  rhinitis. 

Obstruction  of  Stenosis.  This  sometimes  causes  the  greatest  discomfort 
to  the  patient.  There  may  be  simply  a  sense  of  stuffiness  and  fulness  in 
the  nasal  and  frontal  region,  or  complete  obstruction,  causing  inability  to 
breathe  through  the  nose.  It  occurs  in  all  the  obstructive  diseases  of 
the  nose  and  naso-pharynx ;  in  acute  rhinitis,  in  chronic  inflammation 
(except  the  atrophic  form),  in  hyperemia,  the  hypertrophies,  polyps, 
tumors,  deviations  of  the  septum,  foreign  bodies  and  adenoid  vegetations. 

Deafness  is  present  when  the  Eustachian  tubes  are  invaded  or 
obstructed  from  inflammation  or  stenosis.  When  associated  with  anos- 
mia it  may  be  of  central  origin.  Tinnitus  aurium  frequently  accompanies 
the  deafness. 

Cough.  (This  is  of  a  character  known  as  irritative.)  The  discharge 
may  pass  into  the  pharynx  and  the  larynx,  and  set  up  an  irritation 
causing  cough.  It  occurs,  therefore,  in  the  catarrhs  and  obstructive 
diseases,  and  is  not  diagnostic  of  any  nasal  condition.  When  the  nos- 
trils  are  too  wide,  as  in  atrophic  rhinitis,  cough  may  occur  because 
irritating  particles  are  admitted  through  the  widened  aperture. 

The  Data  Obtained  by  Observation. 

The  Objective  Symptoms.  Of  the  general  objective  symptoms, 
fever  has  been  noted.      In  certain  affections  of  the  nose  defective  devcl- 


196  SPECIAL  DIAGNOSIS. 

oprnent  of  the  general  system  is  observed.  This  is  particularly  the 
case  in  adenoid  vegetations  of  the  naso-pharynx  in  children.  (See 
Diseases  of  the  Pharynx.) 

Local  Examination.  The  Exterior.  The  external  appearance  of 
the  nose  is  of  diagnostic  significance  when  marked  deformity  takes 
place.  Its  true  shape  is  changed  in  myxoedema  (q.v.).  It  is  changed  in 
disease  of  the  bone  due  to  syphilis.  The  bridge  of  the  nose  is  sunken 
or  depressed.  It  must  not  be  confounded  with  the  depression  that 
occurs  in  fracture.  The  nose  may  be  broadened  in  cases  of  tumors  of 
an  expanding  nature  in  the  nasal  cavities.  The  local  change  soon 
extends  to  the  cheek.  The  nose  is  also  the  seat  of  eruptions,  as  acne 
and  hyperemia,  but  they  are  usually  of  local  origin.  They  may  be 
suggestive  of  a  gouty  diathesis. 

Internal  Examination.  The  examination  of  the  cavities  of  the  nose 
consists  of  two  procedures,  both  of  which  are  necessary  to  determine 
with  accuracy  the  condition  of  the  organ.      These  are  : 

1 .  Anterior  Rliinoscopy.  For  this  are  needed  a  good  light,  a  nose 
speculum  of  some  form,  probes,  a  10  per  cent,  solution  of  cocaine,  and 
a  head-mirror  with  central  opening. 

The  examiner  proceeds  as  follows  :  The  patient  is  seated  facing  the 
surgeon,  with  the  light  behind  and  at  one  side  of  the  head,  as  nearly 
as  possible  on  a  level  with  the  eye  of  the  operator.  He  must  sit  with 
shoulders  and  head  a  little  forward.  The  operator  adjusts  his  head- 
mirror  so  that  the  central  aperture  is  in  front  of  his  own  eye,  and  the 
reflected  light  falls  on  the  nose  of  the  patient.  It  is  very  important  for 
nose- examination  that  the  operator  look  through  the  aperture  and  not 
under  the  mirror.  The  speculum  is  then  taken  in  one  hand  and  the 
nostril  dilated  so  that  the  view  of  the  interior  is  unobstructed.  Do  not 
try  to  dilate  the  bony  part  of  the  nose,  but  only  the  nostril.  Proceed 
from  before  backward  with  the  examination,  carefully  focussing  the 
light  on  each  part  in  succession,  and  gradually  tilting  the  head  of  the 
patient  backward.  Thus  the  floor  of  the  nose,  the  septum,  inferior 
turbinated  bones,  middle  turbinated  bones,  and  sometimes  the  superior 
turbinated  bones,  are  brought  into  view  successively.  In  a  broad  nose 
one  may  at  times  see  the  posterior  wall  of  the  pharynx,  which  is  dis- 
tinguished by  its  peculiar  wave-like  movement  when  the  patient  swal- 
lows. The  use  of  the  probe  is  important,  and  without  it  no  positive 
diagnosis  can  be  made.  With  the  probe  the  operator  tries  the  condi- 
tion of  the  mucous  membrane,  tests  the  consistency  of  tumors  or  hyper- 
trophies, and  so  judges  of  the  character  of  the  condition.  After  this 
the  enlarged  parts  should  be  touched  with  cocaine  and  the  result 
observed.  Contraction  of  a  swelling  under  its  influence -proves  its 
vascular  origin. 

2.  Posterior  Rhinoscopy.  This  is  the  most  difficult  part  of  the 
examination  and  requires  much  practice  on  the  part  of  the  operator. 
The  instruments  needed  are  a  tongue  depressor,  head-reflector,  two 
sizes  of  throat-mirrors,  a  palate-hook  or  flat  strings  for  holding  forward 
the  soft  palate,  and  a  curved  applicator  for  cocaine,  or  a  spray-bottle 
with  tip  turned  upward. 

The  patient  is  seated  as  before,  the  tongue  held  down  by  the  tongue- 


DISEASES  OF  THE  NOSE  AND  LARYNX. 


197 


depressor,  and  the  patient  is  told  to  breathe  freely  through  both  month 
and  nose.  The  light  is  directed  into  the  pharynx  and  a  mirror  of  the 
largest  possible  size  inserted  carefully  behind  the  soft  palate.  The 
proper  angle  and  the  movement  necessary  to  bring  all  parts  into  view 
can  only  be  learned  by  practice.  As  a  rule,  it  is  best  to  hold  the 
handle  well  up  at  first,  and  note  the  condition  of  the  vault  of  the 
pharynx,  then  gradually  depress  it,  examining  the  choanse  from  above 
downward.  Do  not  keep  the  mirror  too  long  in  the  throat.  It  is 
better  to  insert  it  several  times  than  to  weary  the  patient  by  attempting 

Fig.  23. 


e 


lihinoscopic  mirror  in  position.    (Boswokth.) 

to  sec  everything  the  first  time.  After  the  choame  have  heen  examined 
;i  turn  of  the  mirror  to  either  side  will  bring  into  view  the  orifices  of 
the  Eustachian  tubes,  and  the  examination  is  complete.  If,  after 
repeated  attempts,  it  is  found  to  be  impossible  to  sec  (lie  posterior  nares, 
one  must  first  seek  to  accustom  the  patient  to  the  presence  of  the  instru- 
ments; if  this  fails,  it  may  be  necessary  to  resort  to  the  palate  hook  or 
the  cords  to  hold  the  uvula  forward.  The  best  hook  is  White's.  It 
is  necessary  to  apply  cocaine  to  the  soft  palate  before  inserting  the  hook. 
Another  plan,  which  is  preferred  by  some,  is  to  take  the  flat  cords  used 


198 


SPECIAL  DIAGNOSIS. 


for  corset-laces,  soak  them  in  mucilage  and  dry  them.  These  are  then 
stiff  enough  to  pass  through  the  nostril,  yet  flexible  enough  to  pull 
down  and  out  through  the  mouth  with  forceps.  Then  by  drawing  for- 
ward both  ends  the  soft  palate  is  pulled  out  of  the  way.  This  is  almost 
always  necessary  when  applications  are  to  be  made  to  any  spot  in  the 
pharynx. 

Sometimes  a  view  of  the  posterior  nares  may  be  obtained  by  making 
the  patient  breathe  in  short,  quick  gasps,  by  which  the  uvula  is  released. 
In  ordinary  breathing  it  is  often  tightly  pressed  against  the  posterior 
wall  of  the  pharynx. 


Fig.  24. 


Rhinoscopic  image. 
1.  Vomer  or  nasal  septum.    2.  Floor  of  nose.    3.  Superior   meatus.    4.  Middle   meatus.    5. 
Superior  turbinated  bone.    6.  Middle  turbinated  bone.    7.  Inferior  turbinated  bone.    8.  Pharyn- 
geal orifice  of  Eustachian  tube.    9.  Upper  portion  of  Rosenmiiller's  groove.    11.  Glandular  tissue  at 
anterior  portion  of  vault  of  pharynx.    12.  Posterior  surface  of  velum.    (Seiler.) 

The  above  methods  enable  us  to  determine  the  nature  of  the  discharge, 
the  presence  of  ulceration  or  perforation,  and  the  condition  of  the  entire 
nares.  Deviations  of  septum,  enlargement  or  contraction  of  turbinated 
bones,  and  the  presence  of  foreign  bodies  or  abnormal  growths  are 
also  detected. 

Palpation.  The  probe  is  used  to  determine  the  character  of  enlarge- 
ments or  tumors,  and  the  patulency  of  foramina;  also  to  examine  the 
mucous  membrane  as  to  iuduration  and  the  presence  of  caries  or  necro- 
sis. By  the  finger  the  naso-pharynx  is  palpated  to  confirm  the  results 
of  rhinoscopy.  In  this  manner  adeuoid  vegetations  and  hypertrophy  of 
the  inferior  turbinated  bones  are  detected.  The  finger  should  be  pro- 
tected by  the  use  of  a  mouth-gag  or  by  a  jointed  thimble. 

Color  of  the  Mucous  Membrane.  The  observer  may  find  it  unusually 
pale.  This  is  seen  in  tuberculosis  and  in  atrophic  rhinitis.  If  a  pro- 
tuberent  mass  is  observed  to  be  transparent  and  shining,  as  well  as  pale, 
it  is  due  to  a  polypus.  If  the  mucous  membrane  is  bright  red,  it  may 
be  due  to  acute  inflammation,  to  glanders,  or  to  syphilis.  It  is  dull 
red  in  chronic  catarrhs  and  caseous  rhinitis.  The  coatings  of  the 
mucous  membrane  are  of  significance.  If  a  dry  mucus  covers  the  part, 
it  is  due  to  dry  catarrh ;  on  the  other  hand,  a  dirty-gray  membrane  is 
indicative  of  diphtheritic  rhinitis. 


DISEASES  OF  THE  NOSE  AND  LARYNX.  199 

Ulceration  of  the  Mucous  Membrane.  Ulceration  is  usually  a  mani- 
festation of  lupus,  tuberculosis,  or  tertiary  syphilis.  In  lupus  the 
ulceration  has  extended  from  the  exterior.  Tuberculous  ulcers  are 
usually  found  in  the  septum.  They  present  a  whitish-gray  surface 
with  elevations  of  infiltrated  tissue.  They  bleed  on  the  slightest  provo- 
cation. The  mucous  membrane  surrounding  them  is  torn.  Tubercle 
bacilli  can  be  found  in  the  scrapings  from  the  ulcer.  In  syphilis  the 
ulcers  are  situated  anywhere  in  the  nares.  They  may  be  mere  super- 
ficial excoriations,  or  deep  serpiginous  ulcers  surrounded  by  an  inflam- 
matory zone.  Caries  can  be  detected  with  a  probe.  The  ulcerated 
surfaces  are  covered  with  a  dry,  greenish  crust. 

Neuro-paralytic  ulcers  are  painless  and  spread  rapidly  over  consider- 
able surface;  they  follow  paralysis  of  the  fifth  nerve.  They  are  dry 
and  sluggish  and  do  not  extend  to  the  skin.  Post-febrile  ulcers  follow 
measles,  scarlatina,  typhoid,  and  variola,  and  are  due  to  rupture  of 
small  abscesses,  with  the  subsequent  formation  of  ulcer.  They  are 
usually  anterior  on  the  septum  or  inside  the  alae,  and  scabs  form  over 
the  surface.  They  are  very  irritable.  Ulcers  may  perforate  the  sep- 
tum or  the  floor  of  the  nose.  They  are  usually  due  to  syphilis.  Simple 
perforating  ulcer  of  neuro-paralytic  origin  may  also  occur. 

Secretion.  The  character  of  the  secretions  is  of  diagnostic  signifi- 
cance. They  may  be  liquid,  semi-solid,  or  solid.  The  liquid  secre- 
tions may  be  serous,  mucous,  or  purulent.  Serous  secretions  occur  in 
acute  rhinitis,  hay  fever,  and  idiopathic  rhinorrhoea,  and  follow  bursting 
of  cysts.  The  secretion  of  mucus  occurs  in  the  later  stages  of  inflam- 
mation of  the  mucous  membrane  and  in  chronic  forms.  A  muco-puru- 
lent  secretion  is  seen  in  chronic  rhinitis,  and  pure  pus  in  abscesses  of  the 
septum  or  cavity.  A  discharge  of  blood  is  known  as  epistaxis  (see 
page  200).  The  semi-solid  secretions  may  be  due  to  mucus  alone,  or 
to  blood-clots  mingled  with  serum  or  with  pus.  The  latter  occur  in 
atrophic  and  hypertrophic  catarrhs.  A  semi-solid  secretion  is  seen  in 
Caseous  Rhinitis.  On  examination  the  cavities  in  this  affection  are 
found  to  be  filled  with  cheesy  matters,  easily  broken  up  with  the  probe. 
The  mucous  membrane  is  dull  red.  The  material  is  discharged  in  masses 
at  intervals  through  the  mouth  or  nostrils,  relieving  the  previous 
extreme  stenosis.  If  neglected  for  a  long  time,  deformity  of  the  face 
and  disease  of  the  bones  and  cartilages  ensue  from  pressure. 

The  solid  secretions  may  be  mucous  crusts,  as  in  acute  and  chronic 
catarrhs,  blood-crusts  after  epistaxis  and  traumatism,  membrane  in  diph- 
theritic rhinitis,  slough  from  ulcers,  and  rliinoliths. 

Microscopical  Examination  of  the  Nasal  Secretion .  The  normal  secre- 
tion from  the  nose  contains  squamous  and  ciliated  epithelium,  isolated 
leucocytes,  and  various  fungi.  The  fluid  is  thick,  alkaline  in  reaction^ 
and  has  a  slight  odor.  It  contains  mucin.  In  disease  of  the  nasal 
cavities  the  fluid  changes.  In  acute  nasal  catarrh  it  is  more  copious 
and  thinner.  It  remains  alkaline,  and  contains  epithelium  and  fungi. 
When  the  stage  of  suppuration  is  reached,  the  secretion  may  consist  en- 
tirely of  pus.  Cerebro-spinal  fluid  may  also  be  discharged  through  the 
nose  in  certain  brain-tumors.  In  such  fluid  albumin  is  absent.  Detec- 
tion of  this  fluid  is  of  diagnostic  value,  as  it  points  to  the  central  lesion. 


200  SPECIAL  DIAGNOSIS. 

In  diphtheria  the  characteristic  micro-organism  is  seen.  Recognition 
of  glanders  may  be  based  upon  finding  the  bacillus  in  the  nasal  secre- 
tion (see  Blood).  Cultivations  may  be  made.  The  nature  of  ulcers 
may  be  determined  by  microscopical  examination.  The  tubercle  bacillus 
can  sometimps  be  detected.  A  pneumococcus  or  bodies  that  resemble 
it  have  been  found  in  the  secretion  in  ozsena.  Thrush-fungi  have  also 
been  found,  as  well  as  some  mould-fungi.  The  Charcot-Leyden  crys- 
tals are  found  in  the  nasal  secretion  in  asthmatic  patients,  and  some- 
times in  acute  coryza. 

Mouth -breathing.  Much  valuable  information  is  obtained  by  noting 
the  breathing  and  the  condition  of  the  voice.  Mouth-breathing  may 
be  present  if  the  face  is  drawn  and  vacant,  and  there  are  cracks  and 
fissures  in  the  mouth.  With  mouth-breathing  the  voice  is  usually 
nasal.  The  resonating  quality  is  lost  entirely.  Snoring  accompanies 
these  conditions,  and  they  are  all  due  to  obstruction  of  the  nares.  (See 
Obstructive  Symptoms.) 

Epistaxis.  The  blood  may  flow  in  drops,  or  a  continuous  stream 
may  pour  out  from  the  anterior  nares.  Sometimes  it  falls  into  the 
pharynx  and  is  hawked  up,  or  is  swallowed  and  then  vomited. 

It  may  be  due  to  local  causes,  or  to  constitutional  conditions.  Trau- 
matisms (scratching  the  nose),  new  growths  and  foreign  bodies  are 
causative  agents;  it  may  be  due  to  fractured  skull.  Local  causes  :.  On 
inspection,  the  cause  may  be  found  in  enlarged  veins  at  the  anterior 
inferior  portion  of  the  septum,  a  bleeding  ulcer,  a  new  growth,  or  the 
ulceration  of  a  foreign  body.  The  general  conditions  which  are  causal 
are:  (1)  Plethora  ;  (2)  engorgement  due  to  the  ascent  of  an  elevation; 
(3)  all  forms  of  anaemia;  (4)  in  haemophilia;  (5)  cerebral  congestion 
and  severe  headache;  (6)  in  the  commencement  of  fevers,  particularly 
typhoid  fever,  it  is  common.  In  children  exposed  to  the  sun,  and  after 
exertion,  it  is  of  frequent  occurrence,  and  is  seen  often  at  puberty  in 
delicate  children. 

Disease  of  the  Nose. 

Catarrhs  of  the  Nose      These  may  be  acute  .or  chronic. 

Simple  Acute  Rhinitis.  Acute  Coryza,  "  Cold  in  the  Head." 
Beginning  with  a  feeling  of  lassitude,  aching  in  the  back  and  limbs, 
and  f everishness,  a  sense  of  fulness  is  felt  in  the  nostrils,  with  sneezing. 
After  twenty-four  hours  an  irritating  discharge  from  the  nostrils  begins. 
During  this  time  the  malaise  has  increased.  The  pain  in  the  forehead 
and  cheeks  has  become  more  pronounced,  and  a  nasal  twang  is  given 
to  the  voice.  The  f everishness  continues,  reaching  101°  in  the  more 
pronounced  cases,  with  thirst  and  loss  of  appetite.  At  the -height  of 
the  fever,  in  forty-eight  hours,  a  crop  of  herpes  very  often  develops 
on  the  lips.  The  general  symptoms  then  subside  and  the  local  symp- 
toms change.  The  discharge  becomes  thick  and  purulent,  the  fulness 
continues,  but  the  pain  is  diminished.  The  inflammation  has  extended 
up  to  the  tear-ducts  and  to  the  eyelids.  The  latter  are  congested  and 
smart  very  much.  Very  frequently,  also,  the  inflammation  extends  to 
the  pharynx,  causing  soreness  of  the  throat  and  stiffness  of  the  neck, 
and  the  larynx  even  may  be  involved.      A  slight  deafness  may  result 


DISEASES  OF  THE  NOSE  AND  LARYNX. 


201 


from  the  inflammation  extending  into  the  Eustachian  tube.  Rhino- 
scopic  examination  of  the  mucous  membrane  shows  it  to  be  red  and 
swollen  during  the  first  day.  The  discharge,  as  above  described,  is 
secreted  from  it.  The  contractile  tissue  over  the  turbinated  bones  is 
congested  and  swollen,  on  account  of  which  the  nasal  passages  are 
occluded.  To  the  probe  the  tissue  is  elastic,  and  it  contracts  promptly 
when  cocaine  is  applied.  The  coryza  may  be  symptomatic  of  measles, 
hay  fever,  or  influenza. 

Fig.  25. 


Vertical  section  through  nasal  cavities.    (Diagrammatic.)    (Setler.) 

1.  Superior  turbinated  bone.    2.  Middle  turbinated  bone,  with  posterior  hypertrophy.    3.  Section 
of  hypertrophied  pharyngeal  tonsil.    4.  Inferior  turbinated  bone.    5.  Orifice  of  Eustachian  tube. 


In  the  Diphtheritic  Form  of  acute  rhinitis  the  diagnostic  symp- 
tom is  the  presence  of  the  false  membrane  in  the  nose.  If,  during  the 
presence  of  diphtheria,  a  sloughing,  coryza  occurs  and  the  cervical  glands 
are  found  to  be  swollen,  careful  examination  of  the  nose  should  be 
made.  The  discharge  is  very  acrid  in  diphtheria,  and  is  almost  sine 
to  cause  excoriation  of  the  upper  lip,  the  presence  of  which  condition 
under  these  circumstances  is  of  great  significance.  On  rhinoscopic 
examination  a  dirty-gray  membrane  is  found  lining  the  nostril  Bac- 
teriological examination  confirms  the  diagnosis. 

Chronic  Rhinitis.  Four  varieties  are  distinguished,  to  all  of 
which  the  term  rtasal  catarrh  is  applied.  In  one  there  is  hypertrophy 
of  the  turbinated  bones;  in  the  second  there  is  extension  of  the  disease 
to  the  post-pharynx — chronic  post-nasal  catarrh;  in  the  third  there  is 
absolute  dryness  of  the  mucous  membrane — rhinitis  sicca,  or  dry  catarrh  ; 
in  the  fourth  there  is  atrophy  of  tie.'  mucous  membrane — atrophic  rhin- 
itis, or  ozeena. 


202 


SPECIAL  DIAGNOSIS. 


In  Chronic  Hypertrophic  Rhinitis,  the  affection  conies  on  grad- 
ually after  repeated  acute  attacks  of  coryza.  The  only  symptoms  may  be 
slight  fulness  in  the  nose  and  a  little  hoarseness  of  the  voice.  In  more 
advanced  stages  the  symptoms  of  stenosis  are  marked  with  oral  breath- 
ing, snoring,  aud  nasal  sound.     There  is  a  constant  discharge  of  muco- 


FlG.  26. 


Dilated  nostril,  showing  anterior  hypertrophy.    (Seiler.) 


pns  backward  into  the  pharynx,  causing  hawking.  The  hearing  is  fre- 
quently impaired,  as  well  as  the  taste  and  smell.  The  discharge  often 
affects  the  larynx,  causing  an  irritating  cough.  The  hypertrophied 
tissue  on  the  turbinated  bones,  and  the  pressure  of  the  bone  on  the 
septum,  may  lead  to  reflex  attacks  of  asthma. 

Fig.  27. 


Rhinoscopic  image  from  a  case  of  posterior  hypertrophy  on  the  middle  turbinated  hone.    (Seiler.) 


Rhinoscopic  Examination.  The  uvula  is  thickened  and  elongated  on 
account  of  the  hawking.  The  outer  surface  or  the  edges  of  the  tur- 
binated bones  are  enlarged  throughout  or  in  localities.  The  mucous 
membrane  covering  these  spots  is  thickened,  hard,  and  rough.  If 
cocaine  is  applied,  the  mucous  membrane  does  not  contract,  as  in  the 
swelling  due  to  hyperemia.  The  posterior  ends  of  the  inferior  or 
middle  turbinated  bones  are  enormously  enlarged,  forming  round  tumors 
which  obstruct  more  or  less  the  posterior  nares  and  project  into  the 
pharynx;  polyps  and  deviation  of  the  septum  complicate  these  cases. 


DISEASES  OF  THE  NOSE  AND  LARYNX.  203 

Chronic  Post-nasal  Catarrh  is  an  extension  of  the  rhinitis 
into  the  pharynx.  It  is  distinguished  by  discomfort  or  pain  in  the  soft 
palate  and  posterior  nares.  There  are  tingling  and  a  sense  of  fulness  at 
the  root  of  the  nose,  with  frontal  headache;  the  patient  complains  of 
a  bad  taste  in  the  back  of  the  mouth  and  of  constant  flow  of  thick 
secretion  into  the  pharynx,  causing  snoring  and  hawking.  The  same 
perversion  of  the  senses  of  taste,  smell,  hearing,  and  of  the  voice  occurs 
as  in  acute  rhinitis.  In  addition  to  the  appearance  in  the  nares,  rhino- 
scopic  examination  discovers  a  mammillated  appearance  of  the  anterior 
Avail  and  floor  of  the  pharynx,  with  thickening  of  the  mucous  mem- 
brane and  posterior  third  of  the  septum.  Headache  seems  to  be  due 
to  the  condition  of  the  pharynx. 

Dry  Catarrh,  or  Khinitis  Sicca,  is  also  chronic  in  its  course, 
accompanied  by  tingling  and  dryness  of  the  nostrils.  A  faint,  musty 
odor  is  detected,  but  there  is  no  discharge  or  sense  of  obstruction.  In 
severe  cases  there  may  be  sharp  pain  in  the  nose  extending  to  the  fore- 
head. 

Rhinoscopic  Examination.  The  mucous  membrane  is  coated  with 
dry  mucus,  while  crusts  form  constantly,  giving  rise  to  much  annoyance. 

Atrophic  Rhinitis,  or  Oz^ina,  is  attended  by  a  sense  of  dryness 
in  the  nose.  Occasional  obstruction  arises  from  accumulation  of  crusty 
otherwise  the  passage  is  unduly  open.  There  are  constant  hawking  and 
spitting  of  brownish-green  crusts,  which  are  often  blood-tinged.  Frontal 
headaches  may  occur  in  paroxysms.  The  patient  is  often  depressed  in 
spirits.  The  odor  is  characteristic,  and  is  diagnostic  if  syphilis  is 
excluded.  The  bridge  of  the  nose  may  fall  in  slightly.  On  rhino- 
scopic examination  the  mucous  membrane  is  found  to  be  thin,  pale, 
hard  to  the  touch,  and  covered  with  a  layer  of  dried  secretions  and 
crusts.  The  nasal  passages  are  abnormally  wide  and  the  turbinated 
bones  very  small.  There  may  be  hypertrophy  in  one  nostril  and  atro- 
phy in  the  other. 

In  addition  to  the  above,  a  so-called  Strumous  Rhinorrhcea  is 
seen  in  scrofulous  children.  There  is  a  continuous  discharge  of  mucn- 
pus  from  the  nostrils,  which  are  obstructed  by  the  swollen  mucous 
membrane,  and  particularly  by  greenish-yellow  crusts. 

Syphilitic  Coryza  is  seen  in  infants  and  young  children  affected 
with  hereditary  syphilis.  The  discharge  is  at  first  thin  and  muco- 
purulent. It  soon  becomes  thicker  and  more  purulent,  later  thin  and 
sanious.  The  nostrils  are  swollen  and  red  at  the  edges,  sometimes  com- 
pletely occluded,  causing  oral  respiration  aud  inability  to  take  the  breasl 
or  bottle. 

Pustules,  fissures,  and  ulcers  are  found  in  the  nose  and  at  the  margin 
of  the  orifices.  They  are  also  seen  in  the  pharynx  and  larynx.  Hem- 
orrhages may  occur.  Other  evidences  of  hereditary  syphilis  are  present.' 
Rhinitis  Caseosa  has  been  described  previously  (see  Secretion). 

Nasal  Polypi. 

Polyps  in  the  nostrils  cause  symptoms  of  stenosis.  A  sense  of  ful- 
ness and  obstruction,  attended  by  oral  breathing  and  snoring,  is  common. 


204  SPECIAL  DIAGNOSIS. 

An  acute  rhinitis  or  damp  weather  aggravates  the  symptoms.  If 
neglected,  conjunctivitis  arises,  on  account  of  pressure  on  the  lacrymal 
ducts.     Epistaxis  and  sneezing  are  of  frequent  occurrence. 

Rhinoscopic  Examination.  The  polypus  is  seen  as  a  grayish-yellow 
or  greenish  shining  mass  projecting  by  a  broad  base  from  the  mucous 
membrane.  The  probe  shows  that  it  is  soft  and  yielding  and  that  it 
can  be  circumscribed. 

Foreign  Bodies. 

Animal  parasites  may  find  their  way  into  the  nostrils,  and  act  as  for- 
eign bodies,  or  substances  may  be  thrust  into  the  nostril.  There  are 
stenosis  and  secondary  ulcerative  rhinitis  with  foetid  sanious  discharge, 
often  purulent. 

Rhinoscopic  Examination.  The  foreign  body  may  be  seen  at  once  or 
only  an  ulcer  with  granulating  edges.  The  body  is  in  the  ulcer ;  the 
probe,  which  must  be  used  thoroughly,  can  usually  detect  it.  Only  in 
tropical  regions,  usually,  are  parasites  found  in  the  nostrils.  They  are 
the  larva?  of  the  lucilia  hominivora.  It  is  said  that  the  pain  is  so  severe 
at  the  root  of  the  nose,  extending  backward,  as  to  cause  maniacal  deli- 
rium. Sleeplessness  is  marked,  and  there  may  be  extensive  destruction 
of  the  bones  and  skin.  There  is  a  foetid  sanious  discharge.  Simple 
vegetable  or  inorganic  bodies,  as  peas,  beans,  buttons,  hair-pins,  etc., 
cause  pain  which  may  become  intense  if  the  body  is  of  vegetable  origin 
and  swells. 

Rhixoliths  are  foreign  bodies  in  one  sense,  and  yet  they  develop  in 
the  nostrils.  They  are  gray  or  greenish- brown  in  color,  hard  and  rough, 
either  fixed  or  movable.  They  sometimes  cause  pain  and  reflex  neu- 
roses. 

Nasal  Tumors. 

Tumors  of  the  nose  other  than  polypi  partake  of  the  same  character- 
istics as  tumors  in  other  situations,  and  lead  to  symptoms  of  obstruction 
with  internal  and  external  deformity.  In  the  beginning  the  symptoms 
are  similar  to  those  caused  by  a  foreign  body.  Fibroma,  sarcoma, 
osteoma,  and  enchondroma  are  seen.  Malignant  polypi  or  carcinomata 
grow  rapidly.  They  extend  over  a  large  surface  and  are  attended  by 
pain.  They  bleed  easily  and  cause  a  foetid,  sanious,  ichorous  discharge. 
Epistaxis  is  common.  Stenosis  and  deformity  are  marked.  The  glands 
of  the  neck  are  swollen. 

Glanders. 

This  rare  disease  affects  persons  in  contact  with  horses  that  have  it. 
General  symptoms  consisting  of  pain  in  the  trunk  and  limbs,  with 
rigors  followed  by  fever,  occur  first.  Xausea  and  vomiting  and  diarrhoea 
attend  the  first  twenty-four  hours  of  the  attack.  There  may  be  dysp- 
noea. A  typhoid  type  of  fever  is  present.  A  pimple  appears  on  the 
skin,  which  becomes  painful  and  swollen,  and  at  the  same  time  a  thick, 
yellowish  discharge  streaked  with  blood  oozes  from  the  nostrils.  Hard 
pustules  appear  around  the  nose  and  in  other  parts  of  the  body.  Death 
occurs  from  exhaustion.      (See  Glanders,  and  The  Blood.) 


DISEASES  OF  THE  Xnsj-;  AND  LARYNX.  205 

Ulcerative  Diseases  of  the  Nose. 

We  have  to  distinguish  the  syphilitic  and  tuberculous  ulcer  and  the 
nicer  of  lupus.  In  the  former  a  history  of  infection,  or  of  secondary 
and  tertiary  manifestations,  can  be  obtained.  The  stench  of  the  breath 
is  sickening,  and  the  patient  complains  of  stenosis  and  loss  of  smell. 
There  is  some  localized  tenderness,  and  sleeplessness,  debility,  and  ema- 
ciation may  ensue.  In  tuberculosis  ulcers  tend  to  bleed  readily.  They 
are  usually  secondary  to  tuberculosis  in  some  other  region  of  the  respira- 
tory tract.  Microscopic  examination  of  the  scrapings  from  the  ulcer 
reveals  tubercle  bacilli. 

If  ozsena  is  present  in  a  patient  in  whom  lupus  is  seen  on  some  part 
of  the  external  surface,  it  is  probable  that  there  is  also  lupus  of  the 
nasal  passages.  The  ulcers  may  be  followed  by  necrosis  and  caries  of 
the  bones.  If  the  ozsena  is  not  removable  by  antiseptic  sprays,  the 
bones  are  probably  affected.  A  discharge  of  sequestra  makes  the  diag- 
nosis positive.  Rhinoscopy  and  careful  palpation  may  reveal  the  ulcer 
and  a  carious  bone. 

The  Auxiliary  Cavities  of   the  Nose. 

The  Antrum  is  subject  to  abscess,  cysts  and  polypi,  parasites,  and 
tumors. 

Abscess.  An  odor  somewhat  like  that  of  ozsena,  a  putrid  taste,  nau- 
sea, anorexia,  pain  in  the  cheek  and  root  of  the  nose,  often  neuralgia 
in  the  frontal  region,  and  malaise,  are  present.  A  very  characteristic 
symptom  is  the  discharge  of  pus  from  one  nostril  on  leaning  the  head 
forward.     There  is  often  a  bad  tooth  on  the  same  side  in  the  upper  jaw. 

The  Sinusp:s.  The  frontal,  ethmoidal,  and  sphenoidal  sinuses  are 
subject  to  inflammation,  abscess,  traumatism,  and  the  irritation  of  for- 
eign bodies,  usually  parasites. 

The  frontal  sinuses  are  the  only  ones  which  exhibit  external  symp- 
toms. When  these  cavities  are  inflamed  the  patient  complains  of  pain 
and  tenderness  over  the  frontal  protuberances ;  if  the  process  goes  on  to 
the  formation  of  abscess,  there  may  be  redness  and  swelling  and  finally 
fluctuation.  If  the  communication  is  not  closed,  there  is  a  fcetid  dis- 
charge from  the  middle  meatus. 

When  the  sphenoidal  and  ethmoidal  sinuses  are  affected  there  are  no 
external  symptoms  unless  the  enlargement  is  so  great  as  to  affect  the 
orbit.  There  is  deep-seated  pain.  Pus  is  seen  exuding  into  the  supe- 
rior meatus  and  flowing  backward  into  the  pharynx.  Parasites  cause 
intense  pain  and  lead  to  abscess,  caries,  and  necrosis.  Rhinoscopic 
examination  in  disease  of  the  antrum  shows  rough  hypertrophic  enlarge- 
ment on  the  under  surface  of  the  middle  turbinated  hone  and  a  How  of 
pus  into  the  middle  meatus.  Sometimes  a  probecan  be  passed  into  th" 
antrum  from  the  nose.  Often  an  exploratory  puncture  is  necessary. 
When  the  foramen  is  obstructed  there  is  a  dull  aching  pain  in  the  upper 
jaw,  with  deformity  of  the  orbit,  face,  hard  palate,  and  nostril.  Fluc- 
tuation can  usually  be  found  at  some  point  after  a  time. 

The  lacrimal  duct  and  sac  are  often  the  seat  of  inflammation  by  exten- 


206  SPECIAL  DIAGNOSIS. 

sion,  causing  pain,  obstruction  in  the  nose,  and  epiphora.  On  exami- 
nation pus  will  be  seen  flowing  forward  over  the  inferior  meatus.  When 
the  lacrymal  probe  is  introduced  the  ducts  are  found  to  be  painful  and 
obstructed,  and  pus  exudes. 

Reflex  Neuroses. 

Bronchial  Asthma.  Asthma  may  be  due  to  disease  of  the  nose,  but 
the  only  proof  that  it  is  of  nasal  origin  is  that  it  disappears  after  the 
nose  has  been  treated  for  the  various  ailments  that  are  supposed  to  cause 
it.  Hay  fever  is  an  acute  affection  ushered  in  by  paroxysmal  sneezing, 
itching,  and  smarting  of  the  inner  canthus  of  each  eye,  or  of  the  throat 
or  nose.  After  hours  or  days  of  sneezing  coryza  develops  The  disease 
continues  for  a  varying  length  of  time,  is  more  pronounced  at  certain 
seasons  of  the  year,  particularly  the  late  fall.  Coughing  may  be  an 
additional  symptom,  and  paroxysms  of  asthma  may  develop  which  are 
hard  to  distinguish  from  true  bronchial  asthma.  The  attack  may  be 
excited  by  vegetable  emanations,  particularly  the  pollen  of  plants,  but 
other  emanations  may  also  induce  it.  Certain  conditions  of  the  nasal 
mucous  membrane  predispose  to  the  attack.  Local  inflammation  of 
the  nose  or  obstructive  diseases  from  hypertrophies  is  primarily  present. 
To  the  exciting  cause  and  the  local  predisposing  cause  may  also  be 
added  a  neurotic  factor.  The  disease  affects  families  of  nervous  con- 
stitution, and  may  occur  through  several  generations.  It  is  more  com- 
mon in  this  country  than  in  other  countries,  and  dwellers  in  cities  are 
more  subject  to  it  than  residents  in  the  country. 

Idiopathic  Rhinorrhoea.  Characterized  by  a  sudden  profuse  dis- 
charge of  yellowish  water.  It  ceases  as  suddenly  as  it  develops,  and 
is  thought  to  be  due  to  some  functional  derangement  of  the  fifth  nerve. 

Diseases  of  the  Larynx. 

The  structural  composition  of  the  larynx  does  not  differ  from  that 
of  other  parts  of  the  respiratory  passage.  Mucous  membrane,  connec- 
tive tissue,  cartilages,  and  muscle  are  similar  to  the  same  tissues  situ- 
ated elsewhere. 

The  result  of  their  anatomical  association  in  the  larynx  is  the  estab- 
lishment of  the  functions  of  that  organ,  the  formation  of  the  voice  and 
the  admission  of  air.  Now,  the  morbid  processes  that  affect  the  larynx 
do  not  differ  from  morbid  processes  elsewhere  in  which  similar  tissues 
are  involved.  Each  tissue  is  liable  to  congestion,  to  inflammation,  to 
degeneration,  to  new-growth  formation;  the  joints  may  become  anky- 
losed,  the  muscles  either  paralyzed  or  the  seat  of  spasm,,  and  we  have, 
therefore,  all  the  symptoms  common  to  morbid  processes  in  each  class 
of  tissue.  We  meet  with  other  symptonis  besides  which  result  from 
the  anatomical  position  of  the  larynx  and  of  its  functions.  The  narrow 
chink  of  the  glottis  soon  becomes  occluded,  giving  rise  to  dyspno?a. 
Obstruction  to  the  pathway  or  pain  from  inflammation  or  ulceration 
causes  dysphagia.  The  sensitiveness  of  the  mucous  membrane  pro- 
vokes cough  on  the  slightest  provocation.      The  cords  cannot  vibrate, 


DISEASES  OF  THE  NOSE  AND  LARYNX.  207 

or  the  muscles  and  articulations  cannot  move,  and  dysphonia  or  aphonia 
occurs. 

The  larynx  is  a  highly  specialized  organ,  and  is  well  innervated. 
Large  central  nuclei,  connected  by  a  large  nerve  which  passes  over  a 
circuitous  route  and  which  anastomoses  with  other  nerve-cords,  preside 
over  the  function  of  phonation.  Affections  of  the  central  nuclei,  affec- 
tions of  the  nerve-trunk  or  of  adjacent  structures  exerting  pressure 
upon  the  trunk,  have  their  expression  in  disorder  of  the  larynx,  par- 
ticularly if  phonation  is  disturbed.  In  other  words,  the  phenomena 
of  laryngeal  disease  may  be  symptomatic  of  affections  of  the  brain  or 
of  the  nerve-trunk,  as  well  as  of  the  larynx.      (See  Nervous  Diseases.) 

Owing  to  the  anatomical  position  and  special  function  of  the  organ 
the  symptoms  of  disease  of  the  larynx  are  very  striking,  pointing  at 
once  to  the  seat  of  the  trouble.  Laryngeal  affections  are  not  likely  to 
be  mistaken  for  disease  of  contiguous  parts,  although  retro-pharyngeal 
abscess,  abscess  at  the  side  of  the  pharynx,  disease  of  the  thyroid  gland, 
and  inflammation  of  the  lymphatics  or  cellular  tissue  in  the  neck  may 
cause  symptoms  suggestive  of  laryngeal  disease. 

Finally,  morbid  processes  in  the  larynx  determined  by  the  symptoms 
and  physical  appearances  may  be  symptomatic  of  general  processes  : 
acute  inflammation,  of  erysipelas,  typhoid  fever,  smallpox,  or  measles; 
chronic  inflammation  or  ulceration,  of  the  rheumatic  or  gouty  diathesis, 
syphilis,  or  tuberculosis;  scars,  of  syphilis;  ankylosis,  of  rheumatic 
gout.  The  laryngeal  symptoms  of  brain  disease  or  of  affections  of  the 
nerve-trunk  have  been  referred  to. 

The  practical  point  of  all  this  is  that  affections  of  the  larynx  are  not 
due  to  primary  disease  of  that  organ  alone,  but  are  often  secondary 
either  to  general  processes,  or  to  local  morbid  processes  elsewhere. 

Therefore,  when  laryngeal  symptoms  or  lesions  are  observed,  seek 
beyond  the  larynx,  as  well  as  in  it,  for  their  cause. 

The  Data  Obtained  by  Inquiry. 

Subjective  Symptoms.  Pain.  Pain  in  the  larynx  may  be  sharp, 
stabbing  in  character,  or  simply  a  tickling  or  burning  with  a  feeling  of 
pressure.  Pain  is  sometimes  so  intense  as  to  render  speaking  and  swal- 
lowing impossible.  In  acute  laryngitis  the  pain  is  cutting  and  burning. 
In  the  milder  inflammations,  in  dry  catarrh,  and  in  lupus  it  amounts 
to  soreness  only.  The  pain  is  severe  and  sharp  in  cases  of  cancer  and 
tuberculosis,  rarely  in  syphilis,  and  when  foreign  bodies  are  present  in 
the  structures.  The  pain  may  be  very  severe  and  intense  when  there 
is  destructive  ulceration.  It  is  a  diagnostic  symptom  of  perichondritis. 
Usually  the  pain  is  localized  in  the  larynx,  but  in  ulceration  it  may 
extend  to  the  ears.  This  is  particularly  irue  in  carcinoma.  The  pain 
is  propagated  by  the  auricular  branches  of  the  vagus.  Pain  is  increased 
by  pressure  in  all  affections  of  the  larynx,  and  intensified  by  the  acts  of 
swallowing  and  speaking. 

Parcesthesia.  Peculiar  sensations  are  frequently  complained  of. 
They  may  be  burning,  tickling,  or  itching  in  character,  or  it  may  seem 
as  if  a  foreign  body  were  present  in  the  part,  as  a  hair,  or  it  may  moo 


208  SPECIAL  DIAGNOSIS. 

like  a  draught  of  cold  air  striking  the  parts.  Sometimes  after  a  foreign 
body  has  actually  been  present,  the  sensation  of  its  presence  will  continue 
a  long  while  after  its  removal.  A  sense  of  pressure  or  fulness,  the 
feeling  of  a  lump  in  the  throat,  is  frequently  complained  of,  provoking 
a  desire  to  swallow.  The  patient  will  seek  advice  on  account  of  it. 
It  is  known  as  the  globus  hystericus,  and  is  recognized  by  the  absence 
of  local  changes  in  the  larynx,  by  its  association  with  other  phenomena 
of  hysteria,  and  by  its  disappearance  or  aggravation  under  the  influence 
of  excitement.  This  abnormal  sensation  is  seen  in  hysteria  and  hypo- 
chondriasis.  It  is  one  of  the  nerve-perturbations  in  chlorosis  and  anaemia. 

A  feeling  of  dryness  is  frequently  complained  of,  and  attends  the 
acute  stage  of  acute  and  any  stage  of  chronic  laryngitis.  The  sense  of 
fulness,  or  pressure,  or  feeling  of  the  presence  of  a  foreign  body  is  com- 
plained of  in  all  forms  of  laryngitis,  in  croup,  in  oedema  of  the 
glottis,   or  epiglottis,  and  in  syphilitic  infiltration. 

Hypercesthesia  and  Anaesthesia.  When  there  is  hypercesthesia  there 
is  constant  desire  to  cough  (see  page  210),  and  the  act  is  induced  by  the 
slightest  irritation.  The  desire  to  cough,  independently  of  the  act, 
however,  is  of  itself  an  extreme  annoyance.  It  is  a  disagreeable  sensa- 
tion present  in  acute  inflammations  and  in  early  phthisis.  At  times  of 
menstruation  and  during  pregnancy  both  symptoms  are  frequently  com- 
plained of.  Cough  occurs  reflexly  in  dentition.  Hyperesthesia  is 
easily  recognized  with  the  probe.  In  ancesthesia  particles  of  food  fall 
into  the  larynx.  The  mucous  membrane  is  insensitive  to  the  contact 
of  sound.  Anaesthesia  occurs  in  hysteria,  diphtheritic  paralysis,  paral- 
ysis of  the  superior  laryngeal  nerve,  bnlbar  paralysis  and  cerebral  soft- 
ening or  hemorrhage,  or  coma  from  any  cause. 

Mis-swallowing,  or  "  swallowing  the  wrong  way,"  occurs  in  all  con- 
ditions in  which  food  is  allowed  to  enter  the  larynx.  Although  condi- 
tions favorable  for  its  occurrence  are  present  it  may  not  take  place 
unless  the  patient  is  off  his  guard  during  the  act  of  swallowing,  as 
when  he  is  laughing.  It  may  then  occur  even  in  normal  cases.  It  is 
associated  with  anaesthesia  of  the  larynx,  and  occurs  in  central  nerve 
affections  which  cause  that  condition. 

Dyspnoea.  This  is  one  of  the  frequent  symptoms — and  the  most 
serious — of  laryngeal  disease.  It  occurs  when  obstruction  takes  place, 
and  may  be  due  to  spasm,  to  inflammatory  or  oedematous  swelling  of 
the  tissue  in  and  about  the  larynx,  to  tumors  or  foreign  bodies  in  the 
larynx,  to  the  cicatrization  of  ulcers  after  syphilis  or  lupus,  to  paralysis 
of  the  abductors  or  adductors  of  the  larynx.  Disease  of  surrounding 
structures  with  pressure  upon  the  larynx  causes  dyspnoea,  which  is 
similar  to  that  due  to  disease  of  the  organ  itself. 

Dyspnoea  may  vary  in  degree  from  slight  inconvenience  in  breathing, 
noticeable  to  the  patient,  to  the  violent  struggling  for  breath  which  is 
seen  in  cases  of  extreme  stenosis  of  the  larynx.  If  carefully  observed 
in  either  case,  the  larynx  is  seen  to  rise  and  fall.  If  the  obstruction 
is  present  in  its  more  aggravated  form,  the  head  is  bent  back,  the 
neck  stretched,  the  muscles  of  the  neck  contracted.  The  spaces 
above  the  sternum  and  at  the  sides  of  the  trachea  are  drawn  in  with 
inspiration,  and  the   alae  of  the  nose  work  vigorously.      Further  evi- 


DISEASES  OF  THE  NOSE  AND  LARYNX.  209 

dence  that  sufficient  air  does  not  enter  the  lungs  is  found  in  the 
receding  of  the  epigastrium  and  the  drawing  in  of  the  ribs  at  the  base 
of  the  chest  during  the  act  of  inspiration.  At  the  same  time  the  coun- 
tenance is  dusky  or  ashy-gray,  the  lips  become  cyanosed  and  the  nails 
bluish  as  the  dyspnoea  persists  and  increases.  A  cold  perspiration 
breaks  out  on  the  forehead,  and  finally,  from  exhaustion,  the  respiration 
becomes  slower  and  slower  until  mere  gasps  are  seen.  The  heart' s 
action  increases  in  frequency  as  the  stenosis  increases.  Death  usually 
takes  place  from  asphyxia,  the  child  first  falling  into  a  stupor  on  account 
of  carbonic-acid-poisoning.  The  dyspnoea  under  these  circumstances 
in  the  various  degrees  described  is  generally  inspiratory.  Noise  attends 
the  act  of  inspiration,  the  character  of  the  sound  depending  on  the 
nature  of  the  obstruction.  If  the  obstruction  arises  from  simple  spasm, 
or  from  intense  inflammation  of  the  larynx,  without  secretion,  the  sound 
of  inspiration  is  harsh  and  stridulous.  In  obstruction  that  occurs  from 
osdema  or  from  exudation,  as  in  laryngeal  diphtheria,  the  sound  of 
inspiration  is  loud  aud  stridulous,  but  not  shrill.  The  expiration  is 
usually  noiseless  and  prolonged.  The  short,  stridulous,  or  gasping 
inspiration  is  followed  by  prolonged  gentle  expiration.  In  spasmodic 
croup  the  expiration  is  like  snoring.  The  interval  between  expiration 
and  inspiration  is  lessened,  the  respirations  are  hurried. 

Expiratory  dyspnoea.  In  another  form  of  dyspnoea  the  obstruction 
takes  place  when  the  air  is  passing  out  of  the  lungs,  as  in  cases  of  a 
movable  tumor  below  the  vocal  cords.  The  act  of  inspiration  is  com- 
plete, the  act  of  expiration  is  suddenly  checked  by  the  obstruction,  on 
account  of  which  the  lungs  become  overfilled  with  air  and  an  emphy- 
sema develops.  In  another  variety,  laryngismus  stridulus,  the  act  of 
breathing  ceases  in  the  midst  of  inspiration.  Cyanosis  develops  (see 
Color,  page  72).  Dyspnoea  from  disease  of  the  larynx  may  develop 
gradually  and  continue  over  a  long  period  of  time,  or  it  may  be  acute 
in  onset,  depending  upon  the  character  of  the  morbid  process  which  has 
brought  about  the  obstruction.  Acute  paroxysms  of  dyspnoea,  one  of 
which  may  end  in  death,  sometimes  occur  in  the  course  of  affections 
in  which  chronic  dyspnoea  is  present;  thus  sudden  oedema  may  occur 
in  cases  of  syphilitic  or  tuberculous  ulceration. 

Laryngeal  dyspnosa  must  be  distinguished  from  other  forms  of 
dyspnoea  :  1.  Dyspnoea  due  to.  diseases  of  the  heart  and  lungs. 
2.  Dyspnoea  on  account  of  pressure  upon  the  trachea.  The  larynx 
is  not  markedly  moved  during  the  respiratory  acts,  and  the  patient 
bends  the  head  forward  instead  of  backward.  3.  Diseases  which 
cause  dyspnoea  from  pressure  on  the  larynx.  Cellulitis  of  the  neck, 
tumors  of  the  lymph-glands,  goitre,  and  retro-pharyngeal  abscess 
are  provocative  of  this  form  of  laryngeal  dyspnoea.  Examination  of 
the  respective  localities  by  inspection  and  by  touch  reveals  the  cause 
It  may  be  worthy  of  remark  that  dyspnoea  in  diphtheria,  frequently 
thought  to  be  due  to  internal  occlusion,  may  be  due  to  pressure  of 
enlarged  glands  on  the  bronchus  and  larynx. 

Dysphagia.  Difficulty  in  swallowing  is  most  marked  when  destruc- 
tion of  tissue  in  the  larynx  takes  place,  or  when  there  is  acute  inflamma- 
tion about  the  muscles  or  their  attachments;  hence,  when  ulcers,  tubcr- 

14 


210  SPECIAL  DIAGNOSIS. 

culous  or  malignant,  are  present,  or  perichondritis  arises,  the  difficulty 
is  so  great  as  to  prevent  the  taking  of  food.  When  the  epiglottis  is  the 
seat  of  acute  inflammation  there  is  great  dysphagia  on  account  of  pain, 
or  perhaps  on  account  of  the  obstruction.  When  the  epiglottis  is  fixed 
or  ulcerated,  and  in  some  forms  of  ulceration  of  the  larynx,  the  food 
enters  the  larynx,  and  hence  produces  dysphagia. 

Dysphagia  is  recognized  by  pain  and  by  the  falling  of  particles  of 
food  into  the  larynx,  exciting  cough.  It  must  be  distinguished  from 
the  dysphagia  of  pharyngeal  affections  by  ocular  examination,  the  loca- 
tion of  the  pain,  and  the  non-association  of  rheumatism. 

Dysjihonia.  The  most  common  symptom  of  affections  of  the  larynx 
is  disturbance  of  the  function  of  speech.  The  voice  is  changed  in 
character,  or  may  be  lost  in  any  affection  which  causes  swelling  of  the 
mucous  membrane,  or  occlusion  of  the  orifice,  or  which  interferes  with 
the  action  of  the  vocal  cords.  The  voice  may  be  hoarse  in  acute  and 
chronic  inflammations,  in  tumors  and  in  specific  ulcerations  about  the 
larynx,  and  in  paralysis  of  the  cords.  From  simple  hoarseness  it  may 
vary  in  intensity  to  complete  aphonia.  Laryngoscopic  examination  is 
necessary  in  order  to  detect  the  presence  or  absence  of  paralyses.  (See 
Paralyses. ) 

The  character  of  the  voice  may  change.  When  one-sided  paralysis 
of  a  cord  is  present  the  voice  is  flat  and  toneless.  In  cases  of  paresis 
of  the  tensors  of  the  cords  a  falsetto  voice  results.  Diplophonia  occurs 
in  one-sided  paralysis,  and  in  some  cases  in  which  small  tumors  lying 
between  the  cords  come  up  during  the  act  of  phonation  and  form  nodes. 
Two  tones  are  formed  at  the  same  time  in  this  class  of  cases."  Fre- 
quently only  certain  ti  >nes  are  doubled.  The  duration  may  be  significant. 
Hoarseness  of  long  duration  (years)  is  said  to  be  prodromal  of  cancer. 
(Ziemssen.)    . 

Functional  dysphonia  or  aphonia  may  occur  after  excessive  use  of 
the  voice  and  in  hysteria.  Hysterical  aphonia  occurs  in  women  and 
young  girls;  the  laryngos  ope  reveals  nothing;  the  acts  of  coughing, 
laughing,  and  sneezing  are  normal,  and  a  sound  may  be  created  in 
either;  it  appears  and  disappears  suddenly. 

Cough.  (See  Diseases  of  the  Lungs.)  Sometimes  valuable  informa- 
tion is  derived  from  the  character  and  severity  of  the  cough.  Several 
forms  are  noted: 

First,  the  dry  cough,  as  seen  in  acute  laryngitis.  It  is  almost  con- 
stant, and  is  aggravated  when  the  patient  speaks,  takes  fluid,  or  inspires 
deeply.  In  children  it  is  abrupt,  brassy,  or  metallic,  stridulous  or 
whistling,  so-called  "  croup-cough,"  as  seen  in  cases  of  "  false  croup" 
and  laryngitis  with  oedema. 

Second,  a  dry  hoarse  cough  occurs  in  the  course  of  chronic  laryngitis. 

Third,  cough  with  whoop.  With  the  act  of  coughing  a  whooping 
sound  may  be  heard  in  inspiration.  After  rapid  violent  expiratory  acts 
the  whoop  takes  place  with  inspiration.  It  is  spasmodic  and  convul- 
sive, and  is  followed  by  retching,  and  often  by  vomiting. 

Fourth,  the  cough  is  of  such  a  character  as  to  give  one  the  idea  that 
it  is  suppressed  in  membranous  and  cedematous  laryngitis. 

Fifth,  a  cough  frequently  occurs  without  any  local  anatomical  changes 


DISEASES  OF  THE  NOSE  AND  LARYNX.  211 

in  the  larynx,  which  seems  to  be  purely  of  nervous  origin.  Two  forms 
are  seen  :  a.  Paroxysmal  form.  Severe  coughing  occurs  suddenly,  and 
cannot  be  controlled  by  the  patient.  It  ceases  without  cause,  returning 
in  a  few  hours.  There  is  no  expectoration,  b.  It  may  be  continued 
and  rhythmical  in  character.  It  is  not  so  severe  as  in  the  paroxysmal 
form,  but  consists  in  a  regularly  recurring  cough  more  or  less  loud. 
It  does  not  occur  while  eating  or  speaking  and  ceases  entirely  during 
sleep.  It  is  usually  worse  when  the  patient  is  under  observation. 
Examination  with  the  laryngoscope  reveals  absence  of  disease.  This 
form  of  cough  is  seen  after  diphtheria,  when  sexual  disturbances  are 
present,  at  puberty,  in  cases  of  anaemia  and  chlorosis,  or  of  neurasthenia 
or  hysteria.     The  tone  is  usuallv  high. 

Hemorrhages.  Hard  coughing  or  an  unusual  straining  of  the  voice 
may  lead  to  the  occurrence  of  slight  hemorrhage.  Only  after  injuries 
are  hemorrhages  from  the  larynx  at  all  copious.  Moderate  hemorrhages 
occur  in  scurvy,  haemophilia,  hemorrhagic  smallpox,  typhus  fever,  and 
leukaemia. 

Disturbance  of  Co-ordination.  Several  forms  of  such  disturbance 
are  seen.  Spasm  of  the  glottis  may  occur  with  each  effort  to  speak, 
causing  either  serious  interference  or  complete  inability  to  utter  a  word, 
as  in  stuttering.  Sometimes,  instead  of  the  glottis  opening  to  complete 
the  act  of  inspiration,  it  may  close.  Sudden  inspiratory  dyspnoea, 
therefore,  occurs,  and  is  attended  with  stridor. 

General  Symptoms.  In  the  study  of  laryngeal  affections  it  is  well  to 
note  objective  phenomena  distant  from  the  organ  or  of  a  general  char- 
acter: 

1.  Fever,  present  in  acute  laryngitis  and  tuberculous  ulceration.  It 
is  high  in  acute  laryngitis  with  stenosis;  in  tuberculosis  it  is  of  a  hectic 

tyPe-  .  .  . 

2.  Cyanosis  or  cyanosis  and  pallor  in  laryngeal  stenosis. 

3.  Extended  and  dilating  alae  nasi  in  severe  stenosis.  Recession 
at  the  sternal  notch  and  above  the  clavicles,  and  at  the  base  of  the 
thorax. 

4.  Sudden,  cold  sweats  with  pallor,  in  laryngeal  obstruction,  as 
laryngismus  stridulus,  or  when  a  foreign  body  is  present. 

The  Data  Obtained  by  Observation. 

Objective  Symptoms.  The  objective  symptoms  are  determined  by 
inspection  and  palpation.  Inspection  of  the  exterior  of  the  larynx 
reveals  the  presence  of  swelling,  and  the  movements  of  the  organ  as 
a  whole.  Local  swelling;  of  the  tissues  over  the  larynx  may  occur  in 
inflammations  of  the  cartilages;  they  are  usually  of  syphilitic  origin, 
but  may  attend  carcinoma  or  tumor.  There  is  more  or  less  marked 
swelling  in  inflammation  of  the  cartilages,  which  after  a  time  fluctuates, 
and,  when  opened,  discharges  pus  and  necrosed  cartilage.  The  objective 
signs  of  inflammation  are  noted. 

The  movement  of  the  larynx  is  increased  in  cases  of  dyspnoea.  It 
is  accompanied  by  recession  of  the  space's  above  the  sternum  ami  the 
clavicles,  with  clonic  contraction  of  the  sterno-cleido-mastoid  muscle. 


212 


SPECIAL  DIAGNOSIS. 


The  interior  of  the  larynx  is  studied  by  inspection  (laryngoscopy), 
and  by  palpation  (probe  or  fingers). 

Laryngoscopy.  The  first  requisite  is  a  good  light,  sunlight,  a 
good  student' s-lamp,  or  an  Argand  or  Welsbach  gas-burner;  the  elec- 
tric light  is  not  satisfactory.  Second,  a  good  reflector  is  required.  It 
may  be  attached  to  a  head-band  or  a  spectacle-frame.  It  should  be  con- 
cave for  artificial  light,  plain  for  sunlight,  and  should  be  pierced  in  the 
centre.  Third,  laryngeal  mirrors  of  different  sizes  and  a  curved  probe 
complete  the  instruments  necessary  for  examination  of  the  larynx. 


Fig.  28. 


Laryngeal  mirror  in  position,  displaying  the  larnygeal  image.    (Cohen?) 

Examination.  The  patient  is  seated  with  the  source  of  light  at  one 
side  and  behind  him;  the  head  and  shoulders  are  brought  well  forward 
and  the  head  slightly  raised.  The  operator  takes  a  seat  in  front  at  a 
proper  distance  for  the  focal  length  of  the  reflector,  and  focusses  the 
light  on  the  patient' s  mouth,  warms  the  laryngeal  mirror  over  the  flame 
and  tests  its  temperature  on  the  back  of  the  hand.  It  should  be  mod- 
erately heated,  so  that  when  it  is  placed  in  the  mouth  the  vapor  of  the 


DISEASES  OF  THE  NOSE  AND  LARYNX.  213 

breath  will  not  precipitate  on  its  surface.  The  patient  must  open  the 
mouth  and  protrude  the  tongue,  which  is  grasped  between  the  folds  of 
a  napkin  by  the  thumb  and  fingers  of  the  operator.  The  tongue  should 
be  gently  but  firmly  grasped.  The  mirror  is  then  inserted  carefully 
and  quickly,  face  downward,  into  the  pharynx.  Care  must  be  taken 
not  to  touch  the  tongue  or  palate,  otherwise  the  patient  may  be  made 
to  retch  and  become  alarmed.  The  mirror  is  passed  to  the  posterior 
wall  of  the  pharynx,  and  ,  so  directed  that  the  image  of  the  larynx  is 
reflected  to  the  eye  of  the  operator.  The  patient  is  made  to  phonate 
"  a  "  or  '  ee,"  not  "  ah/'  and  then  to  respire.  The  various  structures 
and  the  action  of  the  cords  are  observed.  The  appearances  of  the 
mucous  membrane  are  studied  during  quiet  respiration. 

The  epiglottis  is  very  dependent,  so  that  often  the  larynx  can 
only  be  seen  by  having  the  patient  stand  while  the  operator  remains 
seated.  The  patient's  head  is  bowed  on  his  chest  and  the  examination 
proceeds. 

The  first  examination  may  not  result  satisfactorily,  but  little  being 
observed  on  account  of  the  spasm  of  the  pharyngeal  muscles.  Repeated 
sittings  may  remove  apprehension  and  accustom  the  mucous  membrane 
to  the  presence  of  the  instrument.  This  object  may  be  attained  by 
administering  bromides,  or  by  applying  cocaine  to  the  pharynx. 

The  probe  is  needed  only  to  ascertain  the  consistency  of  tumors  and 
growths.     Cocaine  must  be  applied  before  it  is  used. 

Sputum  The  sputum  from  the  larynx  is  generally  scanty;  it  is  not 
frothy,  and  is  colorless  and  transparent;  it  is  often  discharged  in  small 
globules;  it  may  be  streaked  with  blood.  Sometimes  pseudo-mem- 
branes are  coughed  up.  It  is  doubtful  if  purulent  sputum  ever  comes 
from  the  larynx,  excepting  in  cases  of  perichondritis  in  which  the  abscess 
bursts  into  the  larynx.  Laryngeal  sputum  is  found  in  catarrh  and 
malignant  tumors.  It  is  blood-streaked  when  the  catarrh  is  very 
intense,  or  after  injuries. 

Appearance  of  the  Larynx  in  Health.  Fig.  28  shows  the 
larynx  as  it  is  seen  in  (he  laryngoscopic  mirror.  Above  (upper  part) 
is  the  arched  epiglottis,  below  it  the  cavity  of  the  larynx.  In  the 
centre  are  the  vocal  cords,  white  and  glistening  ;  on  each  side  of  these 
the  pink  folds  of  the  false  cords.  At  the  bottom  of  the  mirror  are  the 
arytenoid  bodies,  and  between  them  the  folds  of  the  inter-arytenoid 
space.  Below  and  outside  the  arytenoid  bodies  are  the  fossa?.  The 
mucous  membrane  is  pink  throughout  except  on  the  cords.  In  respira- 
tion the  arytenoids  separate,  carrying  the  ends  of  the  cords  which  arc 
attached  to  them  with  them,  and  leaving  a  triangular  opening — the 
glottis — through  which  the  rings  of  the  trachea  can  be  seen.  (Fig. 
29.)  In  phonation  the  arytenoids  approach  each  other,  obliterating 
the  inter-arytenoid  space;  the  inner  edges  of  the  cords  come  in  contact 
and  close  the  glottis.  (Fig.  30.)  The  appearances  in  disease  are 
described  under  the  different  diseases.  A  note  must  be  made  of  the 
color  of  the  various  parts,  of  the  presence  or  absence  of  swelling  or 
ulceration,  and  of  the  movements  of  the  parts  concerned  in  phonation. 
The  latter  applies  particularly  to  the  movements  of  the  cartilage  ami 
of  the  cords,  a  full  discussion  of  which  will  be  found  under  Laryngeal 


214  SPECIAL  DIAGNOSIS. 

Paralyses.     Two  conditions  seen  by  the  laryngoscope,  common  to  many 
laryngeal  disorders,  will  be  spoken  of  here. 

Fig.  29.  Fig.  30. 


Laryngeal  image  during  respiration.  Laryngeal  image  during  phonation. 

Anosmia  of  the  larynx  may  be  merely  part  of  a  general  anaemia  from 
any  cause.  In  chlorosis  it  is  seen  before  the  external  appearance  is 
marked.  An  intense  anaemia  of  the  larynx  is  an  early  and  valuable 
symptom  of  pulmonary  tuberculosis.      The  mucous  membrane  is  pale. 

Hypercemia  may  be  active  or  passive.  It  is  readily  recognized  by 
the  intense  redness. 

Active  hypersemia  occurs  with  overstrain  of  the  larynx  (very  fre- 
quent and  often  constant  in  bass  and  baritone  singers) ;  with  irritation 
from  foreign  particles,  as  in  "  swallowing  the  wrong  way;"  inhalation 
of  hot  or  irritating  gases  or  vapors;  in  the  early  stage  of  inflammations, 
syphilitic  infiltrations,  or  ulcerations. 

Passive  hypersemia  occurs  in  general  obstruction  to  the  circulation, 
as  emphysema  or  valvular  lesions;  pressure  on  veins  by  tumors;  forced 
expiration  and  holding  the  breath;  in  paroxysmal  cough,  especially 
whooping-cough.  Active  hypersemias  lead  to  catarrhs,  passive  to 
oedema. 

Acute  Laryngitis.  Acute  laryngitis  is  an  inflammation  of  the 
larynx,  characterized  by  a  sensation  of  fulness  and  dryness  in  the 
larynx,  with  cough,  hoarseness,  and  at  times  dyspnoea.  Several  varie- 
ties are  observed  :  simple  acute  laryngitis,  laryngitis  with  great  stenosis, 
laryngitis  with  membrane,  laryngitis  with  spasm. 

It  is  caused  by  exposure  to  cold  or  by  the  inhalation  of  acrid  vapors. 
Excessive  use  of  the  voice,  particularly  in  a  cold  air,  may  excite  an 
attack.  It  may  be  symptomatic  of  the  eruptive  fevers,  as  measles  or 
smallpox,  or  erysipelas.  Its  occurrence  in  the  course  of  chronic  dis- 
eases must  be  looked  upon  Avith  alarm,  particularly  in  cases  of  Bright' s 
disease,  if  dropsy  is  present  in  other  situations. 

The  attack  begins  with  a  feeling  of  chilliness,  followed  by  fever  of 
varying  degree,  but  usually  mild.  The  patient  complains  of^a  feeling 
of  pressure  and  dryness  in  the  larynx,  or  as  if  a  foreign  body  were 
present.  Some  pain  gradually  develops  in  the  height  of  the  attack, 
never  so  severe  as  to  require  an  anodyne.  From  the  first  there  is 
cough.  It  is  dry  and  hacking,  and  slightly  painful.  In  the  more 
intense  forms  the  cough  is  continuous,  disturbing  the  patient  night  and 
day.  Paroxysms  occur  when  the  patient  speaks  or  takes  food.  First 
the  cough  is  dry;  within  a  short  time  it  becomes  moist,  and  expectora- 
tion of  clear,  transparent  mucus  takes  place.    The  mucus  may  be  tinged 


DISEASES  OF  THE  NOSE  AND  LARYNX.  215 

with  blood.  At  the  end  of  forty-eight  hours  expectoration  becomes 
more  yellowish  and  opaque.  The  voice  may  be  merely  hoarse,  or  may 
be  lost  entirely.  Sometimes  aphonia  without  general  symptoms  occurs 
in  acute  laryngitis.  In  laryngitis  sicca  cough  and  dyspnoea  occur  in 
paroxysms  and  are  not  relieved  until  a  dry  secretion  is  coughed  up. 
The  paroxysms  take  place  at  night  or  in  the  early  morning,  and  may 
cause  retching  and  vomiting.     It  is  seen  in  adults. 

Acute  Laryngitis  with  Stenosis.  No  doubt  some  of  the  cases 
of  so-called  membranous  croup  that  we  see  in  children  are  cases  of 
acute  laryngitis,  with  swelling  and  occlusion  of  the  glottis  by  conges- 
tion and  by  tough  secretion.  CEdema  may  or  may  not  be  present. 
The  attack  begins  with  catarrhal  symptoms.  The  child  is  languid, 
refuses  to  eat,  is  thirsty  and  has  some  chilliness  and  rise  of  temperature. 
"With  the  slight  cough,  which  may  be  shrill,  there  are  hoarseness  and 
some  difficulty  in  breathing,  but  no  pain  on  swallowing.  On  the  sec- 
ond day,  or  after  the  lapse  of  four  or  five  days,  during  which  time  mild 
fever  continues,  the  catarrhal  symptoms  become  more  marked.  The 
voice  is  more  hoarse  or  may  be  suppressed.  The  harsh,  clanging  cough 
becomes  toneless,  and  soon  the  sound  is  suppressed.  Dyspnoea  is  most 
severe,  and  the  aspirations  are  hurried  and  noisy,  attended  by  loud 
whistling  inspiration,  snoring  expiration.  The  stenosis  is  inspiratory, 
and  during  the  day  or  in  the  succeeding  twenty-four  hours  may  become 
very  intense.  It  is  attended  with  violent  efforts  at  breathing,  and  the 
occurrence  of  cyanosis  in  its  most  aggravated  form.  The  larynx  moves 
up  and  down,  the  head  is  thrown  back.  There  is  recession  at  the  root 
of  the  neck  and  along  the  margins  of  the  ribs  and  the  epigastrium. 
The  lower  portion  of  the  sternum  may  be  drawn  in.  Duskiness  of  the 
extremities  and  of  the  lips  is  observed  as  the  steuosis  becomes  more 
marked,  finally  deepening  into  cyanosis.  It  may  be  relieved  from  time 
to  time  by  removal  of  the  obstruction,  which  occurs  after  cough,  vom- 
iting, or  change  of  position.  A  paroxysm  soon  recurs.  With  each 
paroxysm  lividity  becomes  more  and  more  marked,  the  respirations  con- 
tinue hurried.  The  face  becomes  pale,  the  extremities  cold,  and  a  cold 
sweat  bathes  the  brow.  Restlessness  is  characteristic.  The  child  tosses 
about  in  the  bed  or  from  the  bed  to  the  arms  of  the  nurse.  The  heart's 
action  is  increased  each  hour  in  frequency  as  the  stenosis  advances,  and 
becomes  weaker.  As  exhaustion  ensues  and  the  symptoms  of  obstruc- 
tion become  more  marked,  stupor  deepening  into  unconsciousness  devel- 
ops. Convulsions  may  occur  at  the  end.  The  attacks  rarely  recur  if 
the  patient  once  recovers.      They  follow  exposure  to  cold. 

If  recovery  takes  place,  the  child  usually  becomes  more  free  from 
dyspnoea,  the  cyanosis  fades,  and  the  restlessness  disappears.  A.  pro- 
longed sleep  follows  relief,  although  the  voice  may  remain  hoarse  or 
suppressed,  and  the  cough  continue  many  days. 

Laryngeal  Diphtheria.  The  same  symptoms  are  seen  in  cases 
of  membranous  croup  and  laryngeal  diphtheria.  In  the  latter  affection 
there  may  be  a  history  of  exposure  or  of  infection.  With  the  com- 
mencement of  the  attack  the  diphtheritic  patches  may  be  seen  in  the 
fauces  or  nares.      If  a  membrane  can  be  secured  and  a  bacteriological 


216  SPECIAL  DIAGNOSIS. 

examination  made,  the  diagnosis  of  diphtheria  with  stenosis  is  positive; 
enlarged  glands  in  the  neck,  with  more  marked  depression,  a  moderate 
degree  or  entire  absence  of  fever,  and  occurrence  of  early  albuminuria, 
also  point  to  diphtheria.  The  distinction  between  the  two  affections  is 
nevertheless  quite  difficult,  and  as  long  as  there  is  a  shadow  of  doubt, 
for  prophylactic  reasons  the  case  should  be  considered  as  one  of  diph- 
theria. 

Acute  Laryngitis,  with  Spasm.  False  Croup  or  Spasmodic 
Laryngitis.  In  children,  in  addition  to  mild  and  intense  forms  of 
laryngitis,  a  form  is  frequently  seen  associated  with  spasm  of  the  larynx. 
The  catarrhal  symptoms  are  mild,  so  that  the  child  seems  to  be  well 
during  the  day.  Fever  is  absent  and  a  slight  cough  or  luckiness  alone 
calls  attention  to  the  larynx.  After  the  first  three  or  four  hours  of  quiet 
sleep  the  child  suddenly  awakes  with  a  barking  cough,  sits  up  and 
struggles  for  breath.  The  dyspnoea  continues  from  a  few  minutes  to 
an  hour  or  so,  gradually  lessening,  to  disappear  entirely  as  the  child 
lapses  into  sleep.  Throughout  the  next  day  the  child  seems  as  well  as 
on  the  previous  day,  and  the  succeeding  night  is  again  seized  with 
another  attack  of  "croup."  This  may  occur  once  or  twice  during 
the  night.  It  seems  to  be  influenced  by  the  weather.  Damp  days  and 
an  east  wind  are  provocative  of  an  attack.  It  recurs  frequently  during 
the  same  season. 

Laryngoscopic  examination  reveals  the  characteristic  appearances  seen 
in  cases  of  acute  laryngitis.  But  in  children,  in  whom  the  disease 
most  frequently  occurs,  such  examination  cannot  well  be  made. 

Inflammation  of  the  Epiglottis.  The  epiglottis  may  be  in- 
flamed in  cases  of  laryngitis,  or  become  so  independently.  The  sensa- 
tion of  a  lump  in  the  throat  at  the  base  of  the  tongue  or  the  top  of  the 
larynx  is  complained  of,  and  there  is  pain  on  swallowing.  The  pain 
becomes  very  intense  at  times.  Fluids  cannot  be  taken,  for  the  fluid 
enters  the  larynx  when  the  patient  attempts  to  swallow,  because  the  epi- 
glottis does  not  protect  the  glottis.  The  voice  is  usually  clear  through- 
out the  attack,  and  the  general  symptoms  are  not  marked. 

On  laryngoscopic  examination  the  epiglottis  is  seen  as  a  thick,  red 
tumor.      It  can  be  felt  with  the  finder. 

o 

OEdema  of  the  Larynx.  This  condition  arises  in  the  course  of 
acute  laryngitis,  frequently  occurs  in  chronic  diseases  of  the  larynx, 
particularly  if  ulceration  is  present,  and  as  a  complication  of  erysipelas 
and  diphtheria.  In  some  cases  of  Bright' s  disease  it  may  develop 
suddenly. 

In  the  course  of  the  above-mentioned  disease  symptoms  of -laryngeal 
stenosis  may  occur  suddenly.  The  voice  becomes  husky  and  suppressed, 
the  dyspnoea  is  very  extreme,  so  that  in  a  few  hours  grave  symptoms 
of  obstruction  arise.  There  is  no  cough.  The  patient  complains  of 
the  sensation  of  a  foreign  body  and  tries  to  grasp  it. 

On  laryngoscopic  examination  the  epiglottis  and  aryteno-epiglottidean 
folds  are  seen  to  be  swollen.  The  epiglottis  can  usually  be  felt  with 
the  finger.      If  so,  this  fact  is  of  diagnostic  importance. 


DISEASES  OF  THE  NOSE  AND  LAP,  YNX. 


217 


The  Diagnosis  of  Acute  Diseases  of   the  Larynx. 

Acute  affections  of  the  larynx  are  distinguished  from  other  diseases 
without  much  difficulty.  To  recognize  the  various  forms  of  acute 
laryngitis,  however,  is  not  easy.  In  all  there  is  laryngeal  stenosis  to  a 
certain  degree,  and  practically  the  question  to  answer  is,  Which  form 
of  stenosis  is  present  ?  The  accompanying  table  shows  the  differential 
points  for  diagnosis.  It  is  seen  that  the  age,  occurrence  of  previous 
attacks,  the  character  of  the  general  symptoms,  the  existence  of  pre- 
vious laryngeal  disease,  the  association  of  faucial  disease,  the  presence 
or  absence  of  membrane,  and  the  results  of  laryngoscopic  examination 
must  be  considered  before  making  a  positive  diagnosis. 


Simple  Acute  Laryngitis. — "Catarrh  of  Larynx." 

Gradual  onset  of  laryngitis,  with  dyspnoea  very 

slight  or  absent. 
All  ages. 

Fever  of  varying  degree. 
Dry  irritating  cough. 
May  be  hoarseness. 
Pharynx  reddened. 
Gradual  increase  and  decline. 

Larynx  red  and  slightly  swollen,  as  seen  by 
laryngoscope. 

Acute  Laryngitis  with  Spasm. — Spasmodic  Croup. 

May  be  slight  hoarseness  or  cough,  or  none 
Suddenly,  in  night,  child  wakes  with  intense 
dyspnoea  and  crowing  inspiration. 

Children. 

Temporary  high  fever. 

Slight  brassy  cough  during  day. 

May  be  slight  hoarseness  in  day.  Very  hoarse 
in  attack. 


Acute  Laryngitis  with  Stenosis. 

Gradual  onset  of  laryngitis,  but  dyspnoea  de- 
velops to  great  severity. 

Children. 

Fever  of  varying  degree. 

Dry  cough,  often  paroxysmal. 

Hoarseness. 

Pharynx  reddened. 
J  Gradual  increase,  and  either  death  of  patient  or 

decline  of  dyspnoea. 
',  Same,  but  swelling  much  greater. 

Laryngismus  Stridulus. — "Child-crowing." 

No  laryngitis.  Sudden  attacks  of  dyspnoea  with 
crowing  inspiration,  either  day  or  night.  Very 
severe.    May  be  general  convulsions. 

Children  or  hysterical  adults. 

No  fever. 

No  cough. 

No  hoarseness. 


Lasts  a  few  minutes  to  one  hour, 

no  attack  until  next  night. 
Slight  redness,  or  nothing  seen  by  laryngoscope. 

(Edema  of  Larynx. 

Some  inflammatory  disease  of  larynx  exists. 
Rapid  development  of  dyspnoea,  increasing  to 
great  severity. 


All  ages. 

Depends  on  cause. 
No  cough. 
No  hoarseness. 


Increases   steadily  to   climax,  then    death,  or 

decline  of  dyspnoea. 
Epiglottis  and  aryteno-epiglottic  folds  swollen, 

pale,  and  waxy. 

Foreign  Bodies. 

During  eating  or  while  holding  object  in  mouth 
sudden  dyspnoea,  varying  in  intensity  accord- 
ing to  object. 

All  ages. 

No  fever. 

Irritative,  expulsive  cough. 

May  be  hoarseness  or  not. 


Cough  persists  till  removal  of  body,  or  occasion- 
ally the  larynx  becomes  accustomed  to  its 
presence,  and  cough  ceases. 

See  the  foreign  body. 


Occurs  often  in  rhachitic  and  hysterical  cases. 
May  recur,  or    Ends  suddenly,  in  at  most  two  minutes,  and 
occurs  often. 
Nothing  seen  in  larynx. 


Membranous  Laryngitis. — Croup ;  Diphtheria. 

Epidemic. 

Gradually  developing  hoarseness  and  croupy 
cough,  with  low  fever  and  lassitude,  then 
development  of  dyspnoea,  gradually  and  with- 
out intermission,  as  a  rule. 

Children. 

Low  fever  and  depression. 

Croupy  cough,  later  suppressed. 

Very  hoarse. 

Fauces  red  and  often  with  membrane  ;  albumi- 
nuria ;  paralysis. 

Increases  steadily,  broken  by  intense  paroxysms. 
Either  death  or  gradual  improvement. 

Red,  swollen,  and  membrane. 


Pertussis. —  Whooping-cough. 

Epidemic. 

Bronchitis,  with  cough  developing  from  one  to 
three  weeks.  Then  dyspnoea  caused  by  severe 
paroxysm  of  coughing— absent  between  them. 

Children. 

i » 1 1 1 y  the  fever  due  to  bronchitis. 

Intense  paroxysms  of  coughing. 

No  hoarseness. 

HciiiiHThugcs    in    various    places    from    -train    01 

emphysema. 

May  be  death  from  exhaustion,  or  gradual  im- 
provement. 

Nothing  seen,  unless  slight  laryngitis. 


218  SPECIAL  DIAGNOSIS. 


Chronic    Laryngitis. 

Chronic  laryngitis  either  originates  in  an  acute  attack  or  comes  on 
slowly.  Prolonged  use  of  the  voice  in  a  higher  key  than  natural  or 
in  the  open  air,  the  use  of  alcohol,  constant  exposure,  are  exciting 
causes.  It  is  symptomatic  of  syphilis  and  tuberculosis.  It  frequently 
results  from  inflammation  of  the  upper  air-passages,  particularly  chronic 
pharyngitis.  It  occurs  after  middle  life  more  frequently,  and  usually 
in  the  male  sex.  There  is  discomfort  on  long  speaking,  with  dryness 
and  tickling.  At  first  the  secretion  of  mucus  is  very  slight,  but  after 
hawking  and  coughing  it  increases  in  amount.  Hoarseness  occurs, 
and  if  the  patient  is  careless  or  persists  in  the  baneful  occupation,  com- 
plete aphonia  may  result.  The  voice  is  clearest  in  the  morning,  after 
expectoration  of  the  miicus  that  accumulated  in  the  night,  but  becomes 
husky  toward  night.  The  aphonia  may  occur  in  paroxysms,  relieved 
by  coughing  up  a  dry  secretion.  The  cough  is  never  severe.  The 
sputum  is  small  in  amount,  glairy,  and  is  often  in  little  balls  or  crusts. 

Laryngoscopic  Examination.  Hypersemia  and  more  or  less  swelling 
of  the  epiglottis,  the  outer  arytenoid  space,  and  the  false  cords  are  seen. 
The  cords  may  be  uneven,  or  granular  from  nodes.  Fine  threads  of 
secretion,  or  little  balls  of  mucus,  may  also  collect.  Fissures  or  ero- 
sions are  seen  on  the  cords  and  in  the  folds.  In  the  dry  form  of  chronie 
laryngitis  the  mucous  membrane  is  pale  and  thin,  and  crusts  form. 

Acute  Submucous   Laryngitis. 

The  inflammation  extends  to  the  submucous  cellular  tissue.  It  arises 
in  the  course  of  acute  laryngitis,  and  is  the  form  seen  in  traumatism, 
or  from  burns  and  scalds.  The  symptoms  are  those  of  intense  laryn- 
gitis with  stridor.  They  increase  in  severity  until  stenosis  arises.  If 
the  under  surface  of  the  cords  is  affected,  death  will  occur  from 
asphyxia.  Sometimes  the  inflammation  is  circumscribed  and  is  followed 
by  development  of  an  abscess. 

On  laryngeal  inspection  the  diffuse  form  cannot  be  distinguished  from 
ordinary  laryngitis.  The  circumscribed  form  is  recognized  by  a  swell- 
ing on  the  top  of  which  a  yellow  point,  due  to  the  suppuration,  gradu- 
ally appears.  In  the  hypoglottic  form,  or  so-called  oedema  of  the  glottis, 
a  round,  fixed  swelling  is  seen  on  each  side  below  the  vocal  cord,  almost 
entirely  occluding  the  larynx. 

The  chronic  form  of  submucous  inflammation  of  the  larynx  is  usually 
seen  in  drunkards,  and  is  recognized  usually  by  the  laryngoscopic  exam- 
ination. The  symptoms  are  those  of  slight  stenosis.  On  inspection  a 
dirty-red  diffused  or  circumscribed  swelling  of  some  part  of  the  larynx 
is  observed.  It  may  be  seen  on  the  epiglottis,  or  in  the  aryteno- 
epiglottic  folds  below  the  cords. 

Phlegmonous    Laryngitis   or   Perichondritis. 

Inflammation  about  the  cartilages  is  usually  phlegmonous  in  charac- 
ter, and  leads  to  the  formation  of  abscess.      The  collateral  oedema  is  so 


DISEASES  OF  THE  NOSE  AND  LARYNX.  219 

great  as  to  cause  some  obstruction,  with  cough  and  hoarseness.  On 
palpation  the  larynx  is  extremely  tender.  The  pain  is  increased  by 
movement  of  the  larynx,  as  in  speaking  or  swallowing.  If  the  inflam- 
mation involves  the  arytenoid  cartilages,  pain  extends  toward  the  ear, 
the  vestibule  is  swollen,  the  cartilage  fixed.  On  the  other  hand,  when 
the  cricoid  is  diseased,  there  are  pain  on  swallowing  of  solid  food  on 
account  of  interference  with  the  muscular  attachments,  dyspnoea,  and 
paralysis  of  the  posterior  crico-arytenoid  muscles.  Inflammation  of  the 
thyroid  cartilage  may  open  externally  or  internally.  In  the  latter  case 
the  abscess  can  be  seen  in  the  larynx. 

An  examination  by  the  laryngoscope  shows  swelling  or  oedema  so  great 
that  the  parts  cannot  be  well  outlined.  Discharge  of  pus  and  necrosed 
cartilage  confirms  the  diagnosis.  By  means  of  a  sound  the  bare  cartil- 
age can  be  detected,  giving  further  proof  of  the  presence  of  the  disease. 

Neuroses  of  the  Larynx. — Laryngismus  Stridulus. 

Laryngismus  Stridulus,  or  spasm  of  the  glottis,  is  seen  usually  in 
children  that  are  poorly  nourished.  It  is  of  frequent  occurrence  in 
rickets,  indeed  its  occurrence  points  very  strongly  to  the  possibility  of 
that  disease  being  present  in  children  in  whom  the  other  manifestations 
are  obscure. 

The  symptoms  occur  suddenly  and  are  very  alarming.  The  child 
awakes  in  the  night,  and  suddenly  stops  breathing  after  a  few  short 
whistling  inspirations.  The  child  is  seized  with  terror,  which  is  depicted 
on  the  countenance;  the  eyes  stare;  the  face  is  pallid  at  first,  but  rapidly 
becomes  livid.  The  alae  nasi  are  extended,  the  head  is  thrown  back, 
and  the  spine  arched.  A  cold  perspiration  breaks  out  over  the  fore- 
head. Carpo-pedal  spasms  may  occur  and  the  urine  and  fseces  be  dis- 
charged involuntarily.  In  a  few  seconds,  or,  at  most,  two  minutes,  the 
child  draws  two  or  more  deep,  noisy  inspirations,  each  one  lessening  in 
depth  and  sound,  when  color  returns  to  the  face,  the  cyanosis  gradually 
disappears,  and  the  child  becomes  tranquil. 

In  mild  forms  the  child  "  catches  its  breath."  It  holds  its  breath, 
and  then  makes  a  noisy  inspiration. 

Attacks  of  laryngismus  stridulus  are  more  rare  in  adults.  They  may 
occur  in  hysterical  subjects.  In  the  attack  there  occurs  a  series  of 
long,  harsh,  whistling  or  stridulous  inspirations,  followed  by  short, 
noisy  expirations.      Rarely  is  there  complete  closure  of  the  glottis. 

In  both  children  and  adults  general  convulsions  may  occur  during 
the  attack,  or  carpo-pedal  spasms  alone  may  be  seen.  Among  adults 
the  convulsions  occur  only  in  hysterical  subjects. 

Spasm  of  the  glottis  is  a  frequent  complication  of  disease  of  the 
larynx.      It  is  due  to  peripheral  irritation  in  the  idiopathic  form. 

The  diagnosis  of  laryngismus  stridulus  is  based  upon  the  absence  of 
laryngeal  symptoms  prior  to  the  attack,  the  absence  of  cough  or  hoarse- 
ness, and  complete  disappearance  of  all  laryngeal  symptoms  when  bhe 
attack  subsides.  The  absence  of  pain  and  fever  and  of  laryngoscopic 
signs  is  noteworthy.  This  applies,  of  course,  to  spasm  that  occurs 
independently  of  laryngeal  disease. 


220  SPECIAL  DIAGNOSIS. 


Paralyses  of  the  Laryngeal  Muscles. 

They  are  divided  for  convenience  into  groups.  The  symptom  is  dys- 
phoria, which,  with  laryngoscopic  appearances,  leads  to  the  recognition 
of  the  paralysis. 

1.  Paralysis  of  the  Tensors  of  the  Cord.  The  crico-thyroid 
muscle  is  paralyzed;  the  superior  laryngeal  nerve  which  supplies  the 
muscle  is  concerned.  The  voice  is  deep  and  rough,  and  incapable  of 
producing  high  tones.  Usually,  the  whole  nerve  is  involved,  and  the 
result  is  ancesthesia  of  the  larynx  and  paralysis  of  the  epiglottis. 

Laryngeal  Examination.  The  epiglottis  is  fixed,  and  falls  back  against 
the  tongue.     The  glottis  opening  is  a  wavy  line. 

Causal  disease.  The  condition  described  occurs  almost  exclusively 
after  diphtheria. 

2.  Paralysis  of  the  Closers  of  the  Glottis,  or  Adductors 
of  the  Cords.  The  muscles  involved  are  the  crico-arytenoideus  lat- 
eralis, arytenoideus  transversus,  and  the  thyro-arytenoidei  interims  and 
externus.      The  nerve  is  the  recurrent  laryngeal. 

The  symptoms  are  complete  aphonia,  coming  on  suddenly,  and  often 
disappearing  as  suddenly. 

Laryngeal  Examination.  During  phonation  the  cords  remain  in  the 
inspiratory  position.      The  paralysis  may  affect  one  or  both  sides. 

Fig.  31.  Fig.  32. 


Paralysis  of  the  arytenoideus  transversus  in  Paralysis  of  the  thyro-arytenoideus  internus 

phonation .    (Gottstein.)  in  phonation.    (Gottstein.) 

Sometimes  the  arytenoideus  transversus  alone  may  be  affected.  Then 
there  is  hoarseness  or  aphonia.  The  anterior  portions  of  the  cords 
come  together  in  phonation,  but  the  posterior  portions  do  not,  leaving 
a  triangular  opening  posteriorly.      (See  Fig.  31.) 

Or,  the  thyro-arytenoideus  internus  alone  may  be  affected.  There 
is  then  dysphonia  or  aphonia,  as  before,  but  the  cords  come  together  at 
both  extremities  and  remain  apart  in  the  middle,  forming  an  oval  open- 
ing.    (See  Fig.  32.) 

Causal  disease.  These  paralyses  occur  in  hysteria,  catarrh,  or  severe 
overstrain  of  the  voice. 

3.  Paralysis  of  the  Openers  of  the  Glottis,  or  Abductors 
of  the  Cords.  The  muscle  affected  is  the  crico-arytenoideus  posticus, 
and  the  nerve  is  the  recurrent  laryngeal. 

Symptoms.  When  one  side  is  affected  the  respiration  is  free,  but 
there  is  stridor  or  forced  inspiration.      The  voice  is  harsh. 


DISEASES  OF  THE  NOSE  AND  LARYNX.  221 

Laryngeal  Examination.  One  cord  remains  in  the  middle  line.  (See 
Fig.  33.) 

When  both  sides  are  affected  there  is  gradually  developing  inspira- 
tory dyspnoea  with  stridor.      The  voice  is  nearly  normal. 


Paralysis  01  the  left  recurrent  nerve :  inspiration.    (Gottstein.) 

Laryngeal  Examination.  The  glottis  is  a  narrow  cleft  which  becomes 
still  narrower  on  inspection. 

Complete  Paralysis  of  the  Eecurrent  Laryngeal  Nerve. 
Symptoms.  Unilateral  paralysis.  A  weak,  toneless  voice  which  breaks 
into  a  falsetto  when  the  patient  endeavors  to  speak  loud. 

Laryngeal  Examination.  The  cord  and  arytenoid  body  are  in  the 
cadaveric  position,  viz.,  half-way  between  the  phonating  and  the  inspira- 
tory positions.  In  phonation  the  other  cord  passes  beyond  the  middle 
line,  and  the  glottis  is  slanting.  The  edge  of  the  paralyzed  cord  is 
excavated. 

Bilateral  ptaralysis.    Aphonia  and  inability  to  cough  and  expectorate. 

Laryngeal  Examination.  Both  cords  are  in  the  cadaveric  position 
and  their  edges  excavated. 

The  adductors  are  usually  paralyzed  before  the  abductors,  and  one 
can  see  all  the  intermediate  stages  by  close  watching. 

Causal  disease.  The  conditions  which  give  rise  to  the  paralysis  are 
numerous.  It  may  arise  from  simple  catarrh  or  from  hysteria.  More 
often  it  is  due  to  pressure  on  the  vagus  or  recurrent  laryngeal,  or  some 
disease  affecting  these  nerves  or  their  roots. 

The  causes  of  pressure  are  :  Aneurism  of  the  subclavian  or  aorta, 
mediastinal  tumor,  tubercular  bronchial  glands,  the  apex  of  a  tubercular 
lung,  cancer  of  the  oesophagus,  goitre,  or  carcinoma  of  the  pleura. 

The  diseases  are:  Diphtheria,  tumor,  softening  or  hemorrhage  into 
the  brain,  bulbar  paralysis,  neuritis,  typhus,  cholera,  variola,  articular 
rheumatism,  toxaemia  (?),  sclerosis  of  the  cord,  progressive  muscular 
atrophy,  and  paralytic  dementia. 

Tumors  of  the  Larynx. 

Both  benign  and  malignant  growths  are  seen.  They  give  rise  to  the 
same  group  of  symptoms.  At  first  dysphonia  or  aphonia  takes  place. 
The  impairment  of  voice  may  continue  for  a  long  period  of  time  before 
dyspnoea  arises.  This  develops  very  gradually,  and  in  some  few  eases 
is  attended  by  an  irritative  cough.     The  general   symptoms  are  not 


222  SPECIAL  DIAGNOSIS. 

marked  in  benign  cases.  In  the  malignant  forms  they  are  pronounced, 
but  characterized  by  the  development  of  cachexia  later  than  in  carci- 
noma elsewhere. 

The  most  common  form  of  the  benign  growths  is  the  -papilloma. 
The  growth  may  spring  from  the  true  or  false  cords,  the  aryteno- 
epiglottic  ligaments,  rarely  the  posterior  surface  of  the  epiglottis.  The 
tumor  has  a  broad  base.  There  may  only  be  one,  or  it  may  be  multi- 
ple, and  may  vary  in  size  from  a  split  pea  to  a  walnut.  Three  varieties 
are  met  with  :  1.  Small  warty  growths,  usually  on  the  cords,  dark  red 
in  color,  and  seldom  larger  than  a  bean.  2.  Groups  of  raised  white 
papillae  on  a  broad  base,  also  growing  on  the  cords.  3.  Large,  red, 
mulberry-  or  cauliflower-shaped  growths,  partly  villous,  partly  warty, 
which  fill  up  the  whole  larynx. 

Fibroma.  It  appears  as  a  hemispherical,  pedunculated  tumor  of 
dirty-white,  reddish,  or  dark-red  color,  more  or  less  dense  in  consist- 
ency. It  is  usually  single,  and  grows  most  frequently  from  the  cords. 
When  seen  in  its  smallest  size,  it  is  known  as  the  ' '  singer' s  node. ' ' 
It  may  be  as  large  as  a  hazelnut. 

Malignant  Tumors.  In  addition  to  the  symptoms  indicated  in  benign 
tumor,  pain  and  hemorrhage  occur. 

Both  carcinoma  and  sarcoma  are  found  ;  the  latter  is  very  rare. 

Carcinoma.  The  most  common  form  is  the  epithelioma,  although 
the  medullary  and  scirrhus  have  been  described.  The  epithelioma  is 
seen  as  a  circumscribed,  hemispherical,  warty,  or  cauliflower-like  for- 
mation, varying  in  size,  or  as  a  knotty  infiltration  projecting  into  the 
larynx.  The  medullary  form  is  larger,  soft  and  bloody,  and  rapidly 
ulcerates.  Scirrhus  is  firm  and  hard.  The  structure  of  the  larynx  is 
gradually  invaded,  with  necroses  of  the  tissues.  Perichondritis  and 
abscess  frequently  ensue. 

In  carcinoma  of  the  cords  two  kinds  of  growth  are  seen. 

In  the  polypoid  form  the  tumor  develops  on  the  cord  like  a  warty 
growth,  sometimes  papillary  and  of  a  reddish-gray  color.  In  diffused 
cancer  of  the  cord  the  structures  are  red  and  knotty,  and  invade  the 
surrounding  tissue  without  distinct  demarcation. 

Sarcoma.  The  tumor  has  a  broad  base,  is  shining  in  appearance,  and 
sometimes  lobulated.     Sometimes  the  structure  is  dark  red  or  yellow. 

The  diagnosis  of  malignant  disease  of  the  larynx  is  based  upon  the 
association  of  symptoms  of  laryngeal  disease  with  pain,  and  with  the 
characteristic  appearances  found  on  inspection,  on  its  occurring  after 
the  middle  period  of  life,  and  lasting  from  six  to  nine  months  only, 
with  the  development  of  cachexia  and  emaciation  without  fever.  En- 
largement of  the  cervical  glands  points  to  cancer.  Simple  and-syphilitic 
perichondritis  must  be  excluded. 

Tuberculosis  of  the  Larynx. 

The  existence  of  primary  laryngeal  tuberculosis  is  doubtful.  It  can- 
not be  proved  clinically,  and  the  majority  of  cases,  at  least,  arc  second- 
ary to  tuberculosis  of  the  lungs.     The  manifestations  of  tuberculosis  of 


DISEASES  OF  THE  NOSE  AND  LARYNX.  223 

the  larynx  may  be  either  a  simple  persistent  catarrh,  an  infiltration,  or 
an  ulceration.      The  symptoms  vary  according  to  the  le.-ion. 

a.  Catarrh.  There  is  a  slight  hoarseness  and  the  voice  tires  easily. 
Often  paresthesia  or,  peculiar  sensations  in  the  larynx  are  present. 
Cough,  when  due  to  this  alone  and  not  to  the  process  in  the  lungs,  is 
short  and  dry. 

Laryngoscopic  examination  is  either  negative  or  shows  a  peculiar 
anaemia  of  the  mucous  membrane. 

b.  Infiltration.  At  first  the  symptoms  are  those  of  simple  catarrh, 
then  the  alteration  of  the  voice  increases  even  to  aphonia;  there  is  a 
feeling  of  dryness  or  soreness  in  the  larynx,  and  dysphagia.  The  cough 
is  very  slight  and  is  usually  wholly  disguised  by  the  cough  due  to  the 
disease  in  the  lungs.      There  is  some  difficulty  in  expectoration. 

Laryngoscopic  examination.  Attention  is  first  attracted  by  the  marked 
amernia  of  the  mucous  membrane.  At  first  there  are  slight  intumes- 
cences of  tubercular  infiltration,  not  well  outlined,  and  gray  in  color. 
They  are  most  frequently  found  in  the  inter-arytenoid  space,  less  often 
on  the  false  cords  and  arytenoid  cartilages,  rarely  on  the  epiglottis. 

1.  A  hill-like  prominence  between  the  arytenoid  cartilages  either  in 
the  middle  or  on  one  side.     In  phonation  it  presses  between  the  cords. 

2.  When  a  false  cord  is  affected  the  whole  of  it  is  usually  infiltrated, 
forming  a  tumor-like  swelling  which  often  hides  the  vocal  cords. 

3.  Vocal  cords.  Usually  only  one  cord  is  at  first  affected.  It  is 
thickened  and  the  free  border  is  red.  Sometimes  the  free  edge  seems 
split.  The  infiltration  may  extend  to  the  subcordal  region  and  cause  a 
hypoglottic  laryngitis. 

4.  Epiglottis.  Infiltration  of  the  epiglottis  is  rarer  than  oedema  after 
ulceration,  and  care  must  be  taken  not  to  confound  these  conditions. 
The  whole  epiglottis,  or  only  portions  of  it,  may  be  affected.  It  is 
thickened  and  curled  upon  itself,  and  not  freely  movable. 

5.  Arytenoid  cartilages.  They  appear  enlarged  and  puffy,  and  often 
fixed  from  perichrondritis. 

c.  Ulceration.  The  symptoms  are  the  same  as  those  of  infiltra- 
tion, but  the  dysphagia  and  pain  are  greater.     It  occurs  in  the 

1.  Inter-arytenoid  space.  The  mucous  membranes  are  notched  with 
irregular  projections.  When  the  ulcer  is  visible  it  is  irregular  and  of  a 
dirty-gray  color. 

2.  False  cords.  The  ulcers  are  flat  and  aphthous  with  a  pale-white 
base  and  a  membranous  deposit.  The  mucous  membrane  sometimes 
appears  sieve-like. 

3.  Aryteno-epiglottic  ligaments.  The  ulcers  are  superficial  and  run 
lengthwise  of  the  ligament. 

4.  Vocal  cords.  The  ulcers  are  either  on  the  upper  surface  or  on 
the  edge  of  the  cords.  The  former  arc  superficial  and  seldom  destruc- 
tive. Those  on  the  edge  are  either  small  separate  ulcers  or  long  ones, 
affecting  the  whole  border.  The  circumscribed  ulcers  occur  usually 
at  the  posterior  portion  of  the  cord  and  on  the  processus  vocalis.  The 
ulcers  of  the  whole  border  arc  often  very  destructive. 

5.  Epiglottis.  Tubercular  ulcers  of  the  epiglottis  occur  only  on  its 
laryngeal  side.      They  are  either  aphthous  and  superficial,  or  deep,  and 


224  SPECIAL  DIAGNOSIS. 

arise  from  the  breaking  down  of  previous  infiltration.  Sometimes 
tubercles  can  be  seen  at  the  edge  of  the  ulcers,  but  they  are  of  no  diag- 
nostic value,  as  similar  nodes  are  seen  with  non-tubercular  ulcers.  The 
epiglottis  is  usually  thickened  and  oedematous. 

Diagnosis.  Tuberculous  ulcer  occurs  most  frequently  in  the  male 
sex,  and  during  the  period  ranging  from  eighteen  to  thirty  years  of 
age.  If  the  symptoms  develop  in  the  course  of  phthisis,  or  in  case 
that  affection  cannot  be  recognized,  if  there  is  a  history  of  infection, 
or  exposure,  and  if  bacilli  are  found  in  the  sputum,  the  diagnosis  is 
not  difficult.  A  portion  of  the  diseased  mass  may  be  removed  for 
microscopic  examination  or  inoculation.  In  examining  the  secretion 
for  tubercle  bacilli,  it  is  to  be  remembered  that  the  exudation  may  have 
been  brought  up  from  the  lungs.  The  examination  in  cases  of  phthisis 
is  of  little  practical  value,  except  to  determine  whether  the  ulceration 
present  may  be  syphilitic  and  grafted  upon  a  tuberculous  disease  of  the 
lungs.  Enlargement  of  the  glands  of  the  neck  is  often  present,  but  is 
not  diagnostic. 

Fever  is  present,  and,  indeed,  may  be  an  important  diagnostic  feature 
in  doubtful  cases.  The  temperature  should  be  taken  every  two  hours, 
for  the  morning  or  evening  exacerbations  may  not  be  present.  Emaci- 
ation ensues,  and  sooner  or  later  the  hectic  phenomena  and  signs  of 
tubercle  in  other  structures  arise.  When  tuberculous  ulceration  of  the 
larynx  occurs  in  the  course  of  local  pulmonary  tuberculosis  the  disease 
runs  a  much  more  rapid  course. 

The  laryngeal  symptoms  are  not  diagnostic.  Pain  may  be  the  most 
distinct.  The  appearances  observed  by  the  laryngoscope  are  more  char- 
acteristic. Local  anaemia  with  paresthesia,  paresis  of  the  cords,  and 
short  cough,  or  an  obstinate  diffuse  catarrh,  are  suspicious  symptoms. 
The  peculiar  ridged  infiltration  between  the  arytenoids  is  almost  invari- 
ably tubercular. 

Isolated  thickenings  anywhere  in  the  larynx  that  taper  off  gradually 
into  the  normal  tissue  can  be  only  tuberculous  or  syphilitic.  The  regu- 
larity and  number,  with  anaemia  and  lack  of  inflammatory  signs,  will 
usually  distinguish  the  tuberculous  from  the  syphilitic.  The  ulcers  are 
non-erosive.  Syphilitic  ulcers  do  not  often  occur,  except  on  the  edge 
and  lingual  side  of  the  epiglottis  and  on  the  cords.  They  extend  more 
rapidly  than  the  tuberculous,  and  may  be  continuous  with  ulceration  in 
the  pharynx.  The  area  of  ulceration  may  extend  to  the  base  of  the 
tongue,  which  is  very  infrequent  in  tuberculous  disease.  In  syphilitic 
ulceration  scars  or  cicatrices  are  seen,  but  they  are  absent  in  the  tuber- 
culous form.  Laryngoscopic  examination  in  tuberculous  ulceration  is 
difficult,  as  it  causes  great  pain;  in  syphilis  comparatively  Jittle  pain 
attends  examination. 

Syphilitic  Affections  -of  the  Larynx. 

Mucous  patches,  papules,  infiltrations,  or  gummata  may  be  present 
in  the  larynx  for  some  time  without  exhibiting  any  symptoms.  Usually 
a  change  in  the  voice  is  the  first  symptom  noticed,  due  either  to  the 
catarrh  or  to  ulcers,  scars,  infiltrations,  or  gummata  affecting  the  cords. 


DISEASES  OF  THE  NOSE  AND  LARYNX.  225 

There  is  often  a  feeling  of  pressure  or  a  tickling  sensation.  Pain  is  not 
usual,  and,  when  present,  is  very  slight.  Dysphagia  occurs  only  when 
the  epiglottis  is  extensively  ulcerated.     There  is  little  or  no  cough. 

Laryngoscopy  Examination.  The  appearances  vary  with  the 
condition. 

1 .  Catarrh.     ^Nothing  characteristic  to  be  seen. 

2.  Mucous  patches.  These  are  flat  elevations  of  3  to  7  mm.  diam- 
eter, oval  or  circular,  and  of  a  whitish-gray  color.  When  the  epithe- 
lium is  lost  they  appear  yellow  and  purulent.  There  is  no  tendency  to 
ulceration,  and  the  patches  soon  disappear,  even  without  treatment. 
They  occur  usually  from  three  to  nine  months  after  the  infection. 

3.  Infiltrations.  Usually  these  are  overlooked,  as  they  produce  no 
symptoms.  They  are  diffuse  thickenings  in  various  parts  of  the  larynx, 
most  often  on  the  epiglottis.  This  may  be  uniformly  thickened  or  only 
in  part  around  the  edge.  The  cords  may  be  so  swollen  as  to  cause  dysp- 
noea. Usually  an  ulcerated  spot  is  seen  in  the  centre  of  the  infiltration. 
The  mucous  membrane  is  either  normal  or  reddened.  Infiltrations 
appear  three  to  four  or  more  years  after  infection. 

4.  Gummata.  They  appear  as  round  prominences  of  the  same  color 
as  the  surrounding  tissue.  They  occur  on  either  side  of  the  epiglott:s, 
on  the  ary-epiglottic  folds,  often  in  the  inter  arytenoid  space,  on  the 
false  cords,  and  on  the  under  surface  of  the  vocal  cords.  If  they  break 
down,  deep  ulcers  form,  leading  to  extensive  destruction  of  the  parts. 

5.  Ulceration.     Syphilitic  ulcers  are  circular,   deep,  with  a  sharp 
border  and  inflammatory  areola,  and  overlaid  with  a  whitish-yellow 
deposit.      They  develop  from  an  infiltration  or  a  gumma,  and  not  on 
an  unchanged  surface.     Ulcers  on  the  upper  surface  of  the  epiglottis' 
are  always  syphilitic. 

The  diagnosis  rests  upon  the  history  of  infection,  the  objective  signs 
of  syphilis  indicated  by  pigmentation  or  recent  eruption,  scars,  perios- 
titis or  nodes  on  the  bone,  and  enlarged  glands.  The  laryngeal  symp- 
toms are  not  diagnostic,  save  that  pain  is  absent  in  spite  of  extensive 
ulceration,  while  difficulty  of  deglutition  on  account  of  food  entering 
the  larynx  is  of  frequent  occurrence.  The  laryngoscopic  appearances, 
as  indicated  above,  are  characteristic  of  this  affection.  In  obscure 
cases  the  distinctions  spoken  of  in  tuberculosis  are  of  diagnostic  value. 

Although  the  patient  may  be  broken  down  and  cachectic  the  febrile 
range  is  not  high,  unless  perichondritis  occurs,  or  pneumonia  sets  in 
on  account  of  food  in  the  air-passages. 

Lupus. 

In  this  affection,  probably  tuberculous,  there  are  soreness  and  some 
dysphagia  with  slight  hoarseness,  deepening  to  dysphonia  or  even 
aphonia.  In  the  later  stages  dyspnoea  can  arise  from  infiltration  <>r 
scar-contractions.  Lupus  is  usually  present  also  in  the  skim  of  the/ace 
and  in  the  mouth  and  pharynx. 

Laryngoscopic  Examination.  Isolated  or  grouped  nodes  flowing 
together  into  patches  are  seen  most  frequently  on  the  epiglottis.  Later 
ulceration  occurs  with  loss  of  substance  and  scar -formation. 

15 


226  SPECIAL  DIAGNOSIS. 

Lepra. 

The  symptoms  are  clysphonia  and  dyspnoea.  Usually  lepra  is  present 
elsewhere. 

Laryngoscopic  Examination.  The  epiglottis  is  swollen,  red,  and  vas- 
cular, the  arytenoid  bodies  and  false  cords  dark  red  to  bluish,  the  cords 
injected  and  thickened.  Nodes  from  the  size  of  a  pin-head  to  that  of 
a  pea  are  seen  on  the  epiglottis,  arytenoid  bodies,  and  false  cords.  Then 
follow  ulceration  and  loss  of  substance. 

Foreign  Bodies. 

These  may  be  particles  of  food,  false  teeth,  pins,  or  almost  anything 
small  enough  to  enter  the  larynx,  which  could  by  any  possibility  be 
placed  in  the  mouth.  The  symptoms  are  cough,  often  with  spasm  of 
the  larynx  and  dyspnoea.  There  is  pain  only  when  the  foreign  body  is 
sharp  and  capable  of  injuring  the  mucous  membrane.  Hoarseness  is 
observed  when  the  cords  are  interfered  with. 

Laryngoscopie  examination  is  not  always  possible  on  account  of  the 
reflex  spasm.  When  examination  is  possible  the  body  can  usually  be 
seen. 

The  Larynx  in  Other  Diseases. 

In  Nervous  Diseases.  Laryngeal  symptoms  due  to  lesions  of  the  ner- 
vous system.     (See  Cerebral  Localization.) 

Cerebral  hemorrhage.  1.  Aphasia.  The  movement  of  the  muscles 
is  normal,  but  they  cannot  be  controlled  by  the  will.  Caused  by  hem- 
orrhage in  the  cortex  or  along  the  course  of  connective  fibres. 

2.  Recurrent  paralysis.     Due  to  hemorrhage  in  the  medulla. 

3.  Symptoms  of  bulbar  paralysis.     Same  cause. 
JEncephalomalacia.    (Softening.)    When  in  the  brain,  aphasias  result; 

when  in  the  medulla,  bulbar  symptoms. 

Tam,ors  of  Cerebrum.  The  symptoms  are,  according  to  location,, 
aphonia,  aphasia,  or  paralysis  of  the  cords. 

Bulbar  Paralysis.  We  have,  of  course,  the  other  symptoms  of  the 
disease.  The  voice  becomes  weak  and  monotonous  without  modulation. 
High  tones  are  impossible.  It  progresses  to  hoarseness  and  finally 
aphonia.  Particles  of  food  and  drink  enter  the  larynx.  Paresis  or 
paralysis  of  the  cords. 

Multiple  Sclerosis.  The  speech  is  low,  uncertain  and  scanning,  later 
hoarse.  Laughing  and  crying  are  accompanied  by  peculiar  yawning 
inspirations.  Laryngoscopical  examination  :  Slight  paresis  of  the  cords 
is  seen. 

Posterior  Sclerosis  ( Tabes).  The  muscles  act  very  slowly.  Some- 
times symptoms  of  irritation,  as  tickling  or  burning  in  the  larynx, 
with  a  dry  cough,  occasionally  severe  paroxysms  of  coughing  even  to 
spasm  of  the  larynx,  occur.  In  rare  cases  a  phonetic  spasm  has  been 
observed.  Less  often  paresis  or  paralyses  of  the  various  muscles  occur, 
most  frequently  the  posticus,  next  the  recurrent.  Sensibility  may  or 
may  not  be  disturbed. 


DISEASES  OF  THE  NOSE  AND  LARYNX.  227 

Amyotrophic  Lateral  Sclerosis.  There  is  a  mixture  of  bulbar  with 
spinal  symptoms.     (See  Sclerosis.) 

Progressive  Muscular  Atrophy.  Very  late  occurs  this  same  mixture 
of  symptoms. 

Paralytic  Dementia.  There  may  be  disturbances  in  articulation  with 
paresis  and  paralysis  of-  the  cords. 

Chorea.  There  may  be  a  tremor  of  the  cords  from  under-tension, 
but  probably  no  true  choreic  movements. 


CHAPTER   II. 

DISEASES  OF  THE  LUNGS  AND  PLEUE^E. 

The  various  affections  of  the  lungs  occur  without  any  change  in  the 
volume  of  air  in  the  lungs,  or  are  attended  by  an  increase  or  diminu- 
tion in  the  amount  of  air. 

J.   Diseases  -with  Normal  Amount  of  Air. 

Affections  of  the  Bronchial  Tubes,  except  Asthma. 

II.  Diseases  with  Increased.  Amount  of  Air. 

Enlargement  of  the  Chest.  The  enlargement  with  in- 
creased amount  of  air  may  be  unilateral  or  bilateral.  It 
seems  paradoxical  that  the  more  air  there  is  in  the  thorax,  the 
greater  is  the  need  for  air,  and  hence  the  occurrence  of  dysp- 
noea. 

1.  Asthma. 

2.  Emphysema. 

III.  Diseases  with  Diminished  Amount  of  Air. 

A.  The  Consolidations.     The  consolidations  may  be  local, 

unilateral,  or  bilateral. 

1.  The  congestions. 

2.  Pulmonary  embolism  and  thrombosis. 

3.  Pneumonia. 

4.  Broncho-pneumonia. 

5.  Chronic  interstitial  pneumonia. 

6.  Pulmonary  tuberculosis. 

7.  Abscess  of  the  lung. 

8.  Gangrene  of  the  lung. 

9.  Collapse  of  the  lung. 

10.  Cancer  and  other  new  growths  of  the  lung. 

11.  Hydatid  disease  of  the  lung. 

B.  Diseases  of  the  Pleura. 

1 .  Diminished  amount  of  air  from  inhibition  of  movement 

on  account  of  pain. 

2.  Diminished  amount  of  air  from  the  physical  condition 

within  the  thorax. 

The  lungs  are  composed  of    a  relatively  small  amount  of   tissue. 
They  are  made  up  of  tubes  and  canals.     The  tissue  which  composes 
'  the  structure  of  the  lungs  independently  of  the  canals,  the  connective 
tissue  is  liable  to  the  same  morbid  processes  that  affect  it  in  other  situ- 
ations.     But,   curiously,  it  is  not  often  subjected  to  irritants  which 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  229 

cause  acute  inflammation,  while  chronic  inflammations  occur  second- 
arily, in  the  large  majority  of  cases,  to  processes  in  the  channels. 
Diseases  of  the  lungs  are  really  the  disease  of  its  channels,  and  the 
symptoms  that  arise  are  due  to  morbid  alterations  of  them  (1)  by  pro- 
cesses common  to  the  structure  of  such  channels,  and  (2)  by  obstruction 
of  them.  There  are  three  sets  of  channels  :  first,  for  the  passage  of 
air  ;  second,  for  the  flow  of  blood  ;  and,  third,  for  the  flow  of  lymph. 

Symptoms  due  to  the  Morbid  Process.  The  air-tubes  are 
lined  with  mucous  membrane  which  is  subject  to  morbid  processes  that 
attend  any  such  lining — congestion,  or  acute  and  chronic  inflammation 
— with  a  flux  as  the  characteristic  symptom.  The  muscle  and  elastic 
tissue  of  the  canal  become  involved  in  the  process.  The  former  under- 
goes spasm,  with  or  without  mucous  membrane  inflammation  (asthma). 
Grave  consequences  do  not  arise  until  degeneration  takes  place — then 
the  power  of  confining  the  air  or  driving  it  out  is  lost,  and  emphysema 
results. 

In  the  blood-canals,  hyperemia  (congestion),  embolism  and  throm- 
bosis, and  secondary  oedema  take  place  ;  in  the  lymph-canals,  inflam- 
mation (acute  and  chronic  pleurisy),  and  transudation  (hydro-  or 
hsemothorax).  Now,  the  symptoms  that  arise  in  each  or  all  of  the 
above  processes — pain,  local  discomfort,  mucous  or  purulent  discharge, 
serous  or  purulent  exudation,  aud  fever — are  not  different  from  those 
which  are  found  in  diseases  of  similar  tissues  in  other  localities. 

Symptoms  due  to  Obstruction,  or  Functional  Symptoms. 
In  addition  to  these,  however,  there  is  a  group  of  symptoms  due  to 
obstruction  of  the  various  channels,  and  hence,  interference  with  the 
function  of  the  lungs.     The  symptoms  are  purely  mechanical. 

1.  Dyspnoea  occurs  from  obstruction  of  either  the  bronchial  tubes  or 
bloodvessels  in  addition  to  causes  mentioned  below.  It  is  as  pronounced 
in  asthma  or  capillary  bronchitis  as  in  embolic  obstruction  (fat-embol- 
ism) or  congestion  and  stasis  in  the  bloodvessels.  It  occurs  when  the 
canals  are  occluded  by  extrinsic  causes — foreign  bodies  in  the  bronchi, 
or  pleural  effusions. 

2.  Cyanosis.  As  a  sequence  of  the  above  symptoms  we  have  another 
vivid  picture — the  development  of  cyanosis  from  interference  with 
aeration. 

Other  structures  (the  bony  thorax  and  its  muscles)  are  required  for 
the  performance  of  the  function  of  the  lung,  the  aeration  of  the  blood. 
Of  these  we  have  more  particularly  :  first,  muscles,  to  hasten  the  move- 
ment of  the  air  ;  and,  second,  a  nervous  mechanism  to  control  the  move- 
ment of  the  muscles.  Inactivity  of  the  former,  from  pain,  from  debility, 
or  from  paralysis  through  disease  of  the  nerves,  practically  occludes  the 
canals,  for  the  normal  contents  slacken  or  cease  their  movement,  and 
therefore  the  amount  of  air  is  lessened — hence  dyspnoea.  The  nervous 
mechanism  not  only  controls  the  large  muscles  of  the  exterior,  through 
a  centre  stimulated  or  depressed  by  various  influences,  chiefly  the 
blood,  but  also  receives  and  sends  impressions  to  the  muscles  of  the 
canal,  giving  rise  to  (a)  cough  or  (b)  bronchial  spasm  with  dyspnoea. 
This  nervous  mechanism  by  its  centre  of  control  is  in  relationship 
with  higher  and  lower  centres,  and  the  nerve  that  connects  it  with  the 


230  SPECIAL  DIAGNOSIS. 

bronchial  tubes  supplies  other  organs  or  anastomoses  with  other  nerves. 
Hence,  we  niay  have  :  A.  A  central  affection,  causing  pulmonic  symp- 
toms from  the  following  causes — 1.  Because  higher  centres  influence 
the  lower  pulmonary  centre,  as  we  see  in  hysterical  cough,  or  emotional 
cough,  and  in  asthma.  2.  Disease  affecting  the  region  of  the  centre, 
as  in  tumor  or  in  bulbar  or  glosso-labio-laryngeal  paralysis.  3.  Irri- 
tants acting  upon  the  centre,  as  urea,  exciting  ursemic  asthma.  B.  An 
affection  of  the  nerve-trunk,  as  from  the  pressure  of  an  aneurism  or 
morbid  growth.  C.  Reflex  influences  through  the  pneumogastric  and 
correlated  nerves.  The  asthma  of  nasal  disease  or  of  peripheral  irri- 
tation elsewhere,  and  reflex  cough,  is  of  this  nature.  Corollary :  Lung 
symptoms,  chiefly  dyspnoea  and  cough,  may  be  due  to  local  causes 
(affections  of  the  muscles),  or  to  causes  at  a  distance,  operating  directly 
through  the  pneumogastric  centre,  or  the  nerve-trunk,  or  by  anasto- 
moses in  a  reflex  manner.  The  practical  deduction  is  to  look  further 
than  the  lungs  in  the  investigation  of  pulmonic  symptoms.  Lung 
symptoms  are  not  so  often  expressive  of  disease  in  other  parts,  nor  do 
diseases  of  the  lungs  so  often  have  their  expression  in  other  organs,  as 
is  true  in  gastric  diseases. 

Affections  of  the  Pleura.  In  diseases  of  the  pleura,  one  side 
is  usually  affected,  but,  whether  the  disease  is  unilateral  or  bilateral, 
we  have  simple  inflammation,  and  inflammation  with  exudation  into 
the  pleural  cavity.  In  both  forms  there  is  diminution  of  movement, 
and  hence  less  air  entering  the  affected  lung,  although  the  cause  is 
different  in  each  case.  In  acute  inflammation,  the  diminished  amount 
of  air  is  for  physiological  reasons  :  the  movement  of  the  affected  side 
is  inhibited  by  pain — hence  diminution  of  expansion  and  lessened 
ingress  and  egress  of  air.  Enfeeblement  of  breath-sounds  and  fre- 
mitus, with  diminished  expansion,  alone  indicate  the  diminution.  On 
the  other  hand,  in  acute  inflammation  with  exudation,  the  amount  of 
air  is  diminished  for  physical  reasons.  The  effusion  encroaches  upon 
and  causes  diminution  of  the  air-space,  and  hence  lessens  the  amount 
of  air.  It  will  be  remembered  that  the  physical  signs  of  diminution 
in  the  amount  of  air  from  effusion  are  quite  distinct  from  the  physical 
signs  due  to  consolidation. 

The  Lungs  and  Heart.  The  relationship  of  the  pulmonary  vascular 
channels  to  the  remainder  of  the  circulation  is  very  close.  Overfilling 
of  the  pulmonic  bloodvessels,  and  hence  dyspnoea,  may  be  due  to 
alterations  or  changes  in  the  central  pump,  the  heart ;  or  in  the  vessels 
between — as  from  the  pressure  of  an  aneurism.  The  nature  and  impor- 
tance of  any  luug  symptoms  cannot  be  appreciated  without. an  investi- 
gation of  the  heart  and  the  blood-ways.  Many  pulrnoivc  congestions 
are  due  to  dilatation  of  the  heart,  and  are  relieved  by  digitalis.  At 
the  other  end  of  the  beam,  it  may  be.  noted  that  lung  diseases  cause 
heart  disease  ;  from  backward  pressure  of  blood  columns  in  overdis- 
tended  vessels,  a  dilated  right  heart  follows. 

Space  forbids  tracing  out  the  effects  of  the  blocking  of  channels, 
but  it  is  suggestive  that  all  the  aeration  of  the  body  takes  place  through 
the  first  set  of  tubes,  that  all  the  blood  of  the  body  passes  through  the 
second,  and  that  the  third  is  an  enormous  drainage-area  of    lymph. 


DISEASES  OF  THE  LUNGS  AND  PLETJR2E.  231 

The  student  can  readily  appreciate  how  profoundly  diseases  of  the  lungs 
must  affect  the  general  system.  Apart  from  the  nerves,  the  tie  that 
binds  the  other  organs  to  them  is  the  blood.  In  proportion  as  the 
lungs  enrich  it  with  oxygen,  so  the  other  organs  act  with  vigor.  Im- 
perfect oxygenation  soon  causes  diminution  of  all  function,  with  the 
secondary  effect  on  the  blood  of  the  production  of  anosmia,  which  is  seen 
in  all  chronic  lung  affections,  with  its  long  train  of  symptoms. 

Infectious  Diseases.  The  lungs  are  subject,  in  a  high  degree, 
to  one  group  of  processes — those  of  infection.  Pronounced  symptoms 
due  to  the  infection  and  to  the  blocking  of  channels  are  produced. 
They  are  seen  in  tuberculosis,  pneumonia,  the  bronchitis  of  infectious 
diseases,  the  pleurisy  of  septic  processes.  The  general  symptoms  be- 
longing to  such  processes  are  detailed  elsewhere. 

Relative  Value  of  Subjective  and  Objective  Symptoms. 
The  subjective  symptoms  are  few,  and,  as  will  be  seen  later,  are  com- 
mon to  so  many  pulmonary  diseases  that  they  are  of  little  diagnostic 
value.  The  objective  symptoms  are  more  decisive,  and  the  laws  of 
physics  as  applied  to  the  lungs  aid  in  the  distinction.  The  effect 
of  the  occlusion  of  channels  is  mechanical  or  physical,  and  hence  a 
physical  change  in  the  lung  follows.  The  objective  symptoms  occur 
(1)  because  of  the  physiological  movement  of  air.  Sound  attends  the 
movement  of  air  in  health  :  if  the  air-movement  is  checked,  no  sounds 
occur,  or  abnormal  breath-sounds  and  new  sounds  (rales)  are  created. 
They  also  occur  (2)  because  of  physical  changes  in  the  structure.  Air 
is  replaced  by  solid  structure  ;  the  physical  condition  of  the  lung- 
changes.  The  objective  signs  of  these  conditions  are  determined  by 
inspection,  palpation,  percussion,  and  auscultation. 

Diagnosis.  The  diagnosis  of  disease  of  the  lungs  is  attained  by 
the  collection  and  consideration  of  data  obtained  both  by  inquiry  and 
by  observation.  By  inquiry  we  learn,  first,  the  history  of  the  case  ; 
second,  the  subjective  phenomena.  By  observation  the  objective  phe- 
nomena of  the  disease  are  determined.  The  objective  phenomena  are 
secured,  first,  by  physical  examination  ;  second,  by  an  examination  of 
the  sputum  ;  and,  third,  by  an  examination  of  the  fluids  secured  by 
puncture.  The  examination  of  the  sputum  and  of  aspirated  fluids  is 
made  with  the  microscope  and  by  bacteriological  methods. 

It  is  not  usually  difficult  to  distinguish  diseases  of  the  lungs  from 
affections  of  other  structures.  It  is  true,  pleurisy  and  pleurodynia  arc 
often  distinguished  with  difficulty.  Wo  are  called  upon,  also,  to  decide 
between  pleurisy  and  sub-diaphragmatic  inflammation,  a  pleural  and 
hepatic  inflammation,  a  pleuritis  and  pericardial  inflammation,  and 
between  cardiac  and  pulmonary  disease,  especially  when  both  are. pres- 
ent and  it  is  desirable  to  determine  which  is  the  primary  affection. 
The  contiguous  relations  of  the  organs  make  this  necessary,  and  with 
care  in  ascertaining  the  history  and  the  subjective  and  objective  symp- 
toms the  distinction  may  not  be  difficult. 

In  chronic  disease,  affections  of  the  lungs,  of  the  mediastinum,  and 
of  the  great  vessels  must  be  distinguished  from  one  another.  An 
aneurism  or  mediastinal  disease  may  simulate  chronic  phthisis. 

It  often  happens  in  a  pulmonary  disease  that  some  of  its  pr unced 


232  SPECIAL  DIAGNOSIS 

symptoms  may  strongly  point  to  an  affection  other  than  that  of  the 
lungs  ;  thus  the  cerebral  symptoms  of  pneumonia  may  be  held  to  be  clue 
to  meningitis,  or  the  lever  thought  to  be  due  to  typhoid  lever.  On  the 
other  hand,  the  presence  of  a  pulmonary  affection,  as  tuberculosis,  may 
explain  the  nature  of  the  morbid  process  in  other  organs  or  structures. 
Hence  in  all  cases  in  which  there  is  a  possibility  of  secondary  tubercu- 
losis the  lungs  should  be  examined  to  determine  if  they  are  the  seat  of 
the  primary  disease.  In  this  way  the  true  nature  of  a  meningitis,  a 
peritonitis,  or  other  tubercular  affection  may  be  recognized.  So,  too, 
in  secondary  anaemia  and  in  protracted  debility  of  unknown  source  the 
lungs  should  be  examined.  It  must  be  borne  in  mind  also  that  in 
chronic  diseases,  as  chronic  renal  disease,  chronic  arthritis,  diabetes, 
etc.,  pulmonary  tuberculosis  may  set  in  most  insidiously.  In  the  same 
class  of  diseases  pneumonia  is  frequently  the  terminal  affection,  and 
likewise  runs  an  insidious  course.  Finally,  in  the  extremes  of  life 
pulmonary  affections,  as  pneumonia,  present  symptoms  out  of  the  usual 
run.  In  infancy  and  childhood  the  cerebral  symptoms  may  mask  the 
pulmonary  symptoms  ;  in  senility  the  absence  of  cough  or  expectoration 
may  lead  to  the  dismissal  of  all  thought  of  pulmonary  disease.  In 
short,  the  lungs  should  be  examined  in  all  affections. 

Tins  injunction  is  particularly  to  be  observed,  as  lung  diseases  are 
often  secondary  to  other  diseases ;  phthisis,  to  tuberculosis  elsewhere, 
pneumonia  or  pleurisy  to  all  infectious  disorders,  to  Bright' s  disease, 
cancer,  and  diabetes.  Above  all,  the  possibility  of  a  hyclrothorax,  sec- 
ondary to  causes  of  transudations,  must  be  borne  in  mind. 

The  Data  Obtained  by  Observation. 

The  Objective  Symptoms.  By  physical  examination  of  the  lungs 
we  ascertain — 1,  their  degree  of  activity  (movement);  2,  the  physical 
condition  of  the  parts  subjected  to  examination  ;  but  the  disease  is  not 
diagnosticated.  If  abnormal  signs  are  detected,  they  simply  indicate 
an  abnormal  condition  of  the  part,  which  condition  may  be  due  to 
any  number  of  diseases.  As  the  lungs  in  health  contain  air,  any 
physical  change  that  takes  place  causes  either  an  increase  or  a  diminu- 
tion in  the  amount  of  air.  This  may  be  general  (bilateral),  or  limited 
to  one  side  (unilateral),  or  to  a  smaller  area  (local).  In  examining 
the  lungs  we  might  be  content  to  answer  the  question,  Is  there  an 
increased  amount  of  air,  or  a  diminished  amount  in  the  parts  sus- 
pected to  be  the  seat  of  disease  ?  A  correct  answer  to  this  question, 
and  to  an  inquiry  as  to  the  cause  of  the  increase  or  diminution,  would 
explain  any  abnormal  physical  condition.  The  answer  is  determined 
by  percussion.  Fortunately,  however,  we  have  as  adjuncts  the  phe- 
nomena that  can  be  elicited  by  means  of  inspection,  palpation,  and 
auscultation.  These  methods  of  examination  depend  upon  the  move- 
ments of  the  lungs  and  the  sounds  produced  in  breathing  and  speaking. 

Value  of  Inspection  and  Palpation.  Too  much  emphasis  has  been 
laid  in  the  past  on  auscultation  and  percussion  in  the  study  of  lung 
diseases.  It  has  grown  to  be  too  much  the  habit  to  rely  on  these  meth- 
ods, to  the  exclusion  of  the  simpler  and  quite  as  valuable  methods — 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  233 

inspection  and  palpation.  The  latter  have  been  employed  for  a  long 
time  in  the  study  of  the  objective  phenomena  of  disease.  The  former 
are  comparatively  modern  methods,  and  have  required  special  cultiva- 
tion of  senses  not  usually  employed  in  observation,  in  addition  to  ex- 
haustive comparative  research,  to  put  the  findings  on  an  accurate  basis. 
Naturally  they  have  been  given  undue  prominence  as  methods  of  diag- 
nosis. The  pernicious  habit  of  examining  the  patient  without  remov- 
ing the  clothing,  either  from  haste  upon  the  part  of  the  physician  or 
false  modesty  upon  the  part  of  the  patient,  has  unfortunately  also  led 
to  the  neglect  of  inspection  and  palpation.  It  is  proper  to  insist  that 
the  data  obtained  by  inspection  and  palpation  are  as  important  and 
valuable  as  those  obtained  by  other  means.  They  are  even  more  sug- 
gestive or  diagnostic  of  physical  conditions.  The  phenomena  observed 
are  more  positive  and  surrounded  by  fewer  qualifications. 

The  Regions  of  the  Chest.  For  the  purpose  of  bearing  in  mind  the 
relations  of  the  organs  to  the  surface  ot  the  chest,  and  the  localization 
and  proper  recording  of  the  seat  of  the  disease,  the  chest  is  divided 
into  regions.  The  regions  correspond  to  anatomical  points  on  the  sur- 
face of  the  chest,  and  are  subdivided  by  transverse  and  vertical  lines. 
Knowledge  of  the  landmarks  which  indicate  on  the  surface  the  position 
of  the  parts  underneath  is  of  great  importance  in  diagnosis.  The 
regions  in  the  anterior  portions  of  the  chest  are  :  The  supra- clavicular 
region,  above  the  clavicle  ;  the  infra-clavicular  region,  below  the  clav- 
'icle,  extending  to  the  third  rib  ;  the  mammary  region,  from  the  third 
to  the  sixth  rib.  In  the  axilla  two  regions  suffice — the  upper  and  lower 
— the  position  of  the  disease  being  more  definitely  determined  by  asso- 
ciation with  ribs  and  interspaces.  Posteriorly  the  regions  are  :  the 
supra-scapular,  above  the  scapula  ;  the  scapular  region,  and  the  infra- 
scapular  region  ;  the  region  between  the  scapula  and  the  spine  is  known 
as  the  interscapular  region.  The  vertical  lines  are  to  the  right  and  left 
of  the  median  line  :  (1)  the  parasternal  line,  which  is  drawn  downward 
midway  between  the  edge  of  the  sternum  and  the  second  line,  which  is 
(2)  the  mid-clavicular  line,  drawn  from  the  middle  of  the  clavicle,  gen- 
erally passing  through  the  nipple  in  males :  (3)  the  anterior  axillary  line, 
drawn  from  the  anterior  fold  of  the  axilla  ;  (4)  the  mid-axillary  line, 
from  the  centre  of  the  axilla  ;  (5)  the  posterior  axillary  line,  from  the 
posterior  fold  of  the  axilla.  In  the  back  one  line  is  sufficient — the 
scapular  line,  drawn  through  the  angle  of  the  scapula  when  the  arm  is 
at  rest  at  the  side  of  the  patient.  For  transverse  lines  the  ribs  and 
interspaces  are  used.  In  this  way  the  exact  location  of  a  diseased  area 
can  be  indicated.  In  order  that  accuracy  may  attend  its  localization, 
knowledge  of  the  methods  of  determining  the  landmarks,  and  espe- 
cially of  counting  the  ribs,  is  essential. 

The  Angles  of  the  Thorax.  The  costal  angle  is  the  angle  of  the  rib. 
It  varies  during  the  act  of  respiration.  In  inspiration  the  rib  rise-  as 
the  sternum  projects,  and  apparently  elongates;  the  angles  become  more 
obtuse;  in  expiration  the  sternum  falls,  the  ribs  become  more  slanting, 
and  the  angle  is  more  acute. 

The  epigastric  angle.  This  angle  is  formed  by  the  convergence  of 
the  ribs  of  both  sides  to  the  xiphoid  cartilage  of  the  sternum.      On 


234  SPECIAL  DIAGNOSIS. 

inspiration  it  is  obtuse,  increasing  as  the  ribs  rise  ;  in  expiration  it  is 
more  acute. 

Method  of  Counting  Ribs  and  Interspaces.  The  first  rib  corresponds 
to  the  clavicle;  the  first  interspace  is  the  region  between  the  clavicle, 
or  first  rib,  and  the  second  rib;  the  subsequent  number  of  an  inter- 
space corresponds  to  the  number  of  the  rib  above  it.  The  following, 
from  Hoi  den,  is  of  great  importance  to  remember,  particularly  when 
the  ribs  of  fat  persons  are  counted  : 

a.  The  finger  passed  down  from  the  top  of  the  sternum  soon  comes 
to  a  transverse  projection,  slight,  but  always  to  be  felt,  at  the  junction 
of  the  first  with  the  second  bone  of  the  sternum.  This  corresponds 
with  the  middle  of  the  cartilage  of  the  second  rib. 

b.  The  nipple  of  the  male  is  placed  in  the  great  majority  of  cases 
between  the  fourth  and  fifth  ribs,  about  three-quarters  of  an  inch 
external  to  their  cartilages. 

c.  The  lower  external  border  of  the  pectoralis  major  corresponds 
with  the  direction  of  the  fifth  rib. 

d.  A  line  drawn  horizontally  from  the  nipple  round  the  chest  cuts 
the  sixth  intercostal  space  midway  between  the  sternum  and  the  spine. 
This  is  a  useful  rule  in  tapping  the  chest. 

e.  When  the  arm  is  raised  the  highest  visible  digitation  of  the  serra- 
tus  magnus  corresponds  with  the  sixth  rib.  The  digitations  below 
this  correspond  respectively  with  the  seventh  and  eighth  ribs. 

/.  The  scapula  lies  on  the  ribs  from  the  second  to  the  seventh,  inclu- 
sive. 

g.  The  eleventh  and  twelfth  ribs  can  be  felt,  even  in  corpulent  per- 
sons, outside  the  erector  spinse,  sloping  downward. 

h.  One  should  remember  the  fact  that  the  sternal  end  of  each  rib  is 
on  a  lower  level  than  its  corresponding  vertebra.  For  instance,  a  line 
drawn  horizontally  backward  from  the  middle  of  the  third  costal  carti- 
lage, at  its  junction  with  the  sternum,  to  the  spine,  would  touch  the 
body,  not  of  the  third  dorsal  vertebra,  but  of  the  sixth.  Again,  the 
end  of  the  sternum  would  be  at  about  the  level  of  the  tenth  dorsal 
vertebra.  Much  latitude  must  be  allowed  here  for  variations  in  the 
length  of  the  sternum,  especially  in  women. 

It  is  important  to  recognize  the  relation  of  the  ribs  to  the  vertebrae. 
The  first  rib  articulates  with  the  first  dorsal  vertebra,  which  can  be 
located  by  the  position  of  the  prominent  spine  of  the  seventh  cervical 
vertebra  ;  even  in  very  fat  people  this  prominence  can  be  recognized. 
The  remaining  ribs,  except  the  tenth,  eleventh,  and  twelfth,  have 
facets  of  articulation  on  two  vertebrae  ;  as  the  second  rib,  with  the 
first  and  second  thoracic  vertebrae.  The  eleventh  and  twelftlrarticulate 
with  the  eleventh  and  twelfth  thoracic  vertebrae. 

Topographical  Anatomy.  The  following  anatomical  points  are  worthy 
of  remembrance  : 

The  top  of  the  sternum  is  on  a  plane  with  the  lower  border  of  the 
second  dorsal  vertebra  behind.  The  junction  of  the  first  and  second 
portions  of  the  sternum  is  known  as  the  angle  of  Lndwig.  It  is  oppo- 
site the  middle  of  the  second  rib,  and  is  on  a  plane  with  the  lower 
border  of  the  fourth  dorsal  vertebra.      The  junction  of  the  body  of  the 


DISEASES  OF  THE  LUNGS  AND.PLEURJE. 


235 


sternum  to  the  xiphoid  cartilage  is  on  a  plane  with  the  lower  border  of 
the  eighth  dorsal  vertebra. 

The  apex  of  the  diaphragm  is  on  a  level  with  the  eighth  dorsal 
vertebra. 

;    The  trachea  bifurcates  at  the  plane  which  includes  the  angle  of  Lud- 
AvisJ  and  the  fourth  dorsal  vertebra. 

Purulent  effusions  in  the  left  pleural  sac  frequently  point  at  the  fifth 
interspace,  beneath  the  nipple,  because  this  is  the  weakest  point  of  ihe 
chest-covering.  A  little  external  to  the  inferior  angle  of  the  scapula 
and  the  eighth  and  ninth  interspaces  a  similar  weak  point  is  found. 

Limits  of  the  Lungs.  The  apices  of  the  lungs  reach  three  to  seven 
centimetres  (one  and  one-fifth  to  two  and  three-quarters  inches)  above 
the  clavicles  in  front  ;  behind  they  rise  as  high  as  a  line  drawn  trans- 
versely through  the  spinous  process  of  the  seventh  cervical  vertebra. 

Fig.  34. 


Outline  of  the  heart,  its  valves,  and  the  lungs.    (Holden.1 


The  lower  anterior  margin  of  the  right  lung,  when  the  chest  is  passive. 
commences  at  the  insertion  of  the  sixtli  rib  into  the  sternum,  and  runs 
parallel  with  the  upper  border  of  the  sixth  rib  to  the  axillary  line. 
At  this  point  it  descends  to  the  upper  margin  of  the  seventh  rib.  <  >u 
the  left  side  the  lower  limit  extends  as  far  downward  as  the  right. 
Posteriorly,  both  lungs  reach  to  the  tenth  rib.      With  full  inspiration 

the  lungs  descend  both  in   front  and   behind  almost  the  extent  of  

interspace,  while  in  deepest  expiration  they  are  elevated  almost  t<>  the 


236  SPECIAL  DIAGNOSIS. 

original  position.  The  "  complemental  space  "  of  Gerhard t  is  the  space 
at  the  lower  margin  of  the  lung,  and  at  the  point  at  which  the  left  lung 
overlaps  the  heart,  in  which,  during  expiration,  the  surfaces  of  the 
visceral  and  parietal  pleura  come  together.  In  inspiration  the  thin 
layer  of  the  lung  in  both  situations  insinuates  itself  into  this  space. 
The  heart  interferes  with  the  extension  of  the  left  lung.  The  figure 
(34)  shows  the  relationship  to  the  chest-wall.  The  space  is  triangular  in 
shape,  extending  in  the  median  line  from  the  fourth  to  the  sixth  rib. 
The  left  edge  of  the  triangular  area  corresponds  to  the  edge  of  the  left 
lung,  which,  notched  for  the  heart,  diverges  from  the  median  line  and 
runs  along  the  cartilage  of  the  fourth  rib. 

Position  of  the  Lobes.  The  accompanying  diagram  illustrates  the 
position  of  the  lobes  of  the  lungs  anteriorly.  In  the  right  lung  the 
upper  lobe  in  front  extends  to  the  fourth  rib,  in  inspiration  laterally  to 
the  third,  and  behind  to  the  spine  of  the  scapula.  The  lower  lobe 
begins  with  the  spine  of  the  scapula  and  extends  to  the  tenth  rib 
behind,  and  from  the  fourth  to  the  tenth  ribs,  when  fully  expanded, 
in  the  axillary  region.  The  middle  lobe  is  not  seen  behind  ;  it  extends 
between  the  third  and  fourth  ribs  in  the  axillary  region  in  inspiration. 
In  front  it  extends  from  the  lower  margin  of  the  upper  lobe  to  the 
sixth  rib. 

The  upper  lobe  of  the  left  lung  extends  to  the  sixth  rib  in  front  and 
to  the  fourth  interspace  at  the  side.  Behind,  a  small  portion  extends 
above  the  spine  of  the  scapula,  while  the  lower  lobe  extends  from  the 
spine  of  the  scapula  to  the  base  of  the  lung 'behind.  At  the  sides  it 
extends  from  the  lowest  limit  of  the  upper  lobe  to  the  level  of  the 
eighth  rib. 

Inspection.  By  inspection  we  learn  (1)  the  appearance  of  the  ex- 
ternal surface,  (2)  the  shape  and  size,  and  (3)  the  movements  of  the 
chest.  The  second  indicates  the  capacity  of  the  lungs  ;  the  last,  the 
degree  of  functional  activity. 

Methods.  The  patient  must  be  seated,  if  possible,  in  an  easy  posi- 
tion, with  the  light  falling  directly  on  the  part  or  from  the  side.  He 
should  be  viewed  by  the  observer  standing,  first  in  front,  then  behind, 
and  also  from  the  side.  To  observe  the  anterior  portion  it  is  often 
well  to  stand  behind  the  patient  and  look  downward  over  the  shoulders. 
The  arms  should  fall  by  the  side  ;  the  breathing  should  be  quiet  and 
undisturbed  by  talking  or  unusual  movements. 

The  Skin  and  Sabeutayieous  Tissue.  In  health  the  normal  covering- 
should  be  supple,  elastic,  and  of  the  color  previously  described.  It  is 
pale  in  anaemia  and  wasting  diseases;  yellow  in  jaundice;  pigmented 
generally  or  locally  from  causes  previously  mentioned.  It  is  fhe  par- 
ticular seat  for  the  parasitic  disease,  tinea  versicolor,  and,  along  with 
other  non-specific  eruptions,  is  the  seat  of  sudamina.  The  veins 
over  the  surface  of  the  chest  should  not  be  very  distinct.  They  are 
distinct  when  there  is  interference  with  the  circulation  in  the  mediasti- 
num from  the  pressure  of  an  aneurism  or  morbid  growths  obstructing 
the  veins.  They,  along  with  the  cervical  veins,  may  also  be  enlarged 
in  dilatation  of  the  right  heart.  The  capillaries  along  the  base  of 
the  chest  are  often  enlarged  or  more  distinct  than  usual  and  arranged 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


237 


in  a  bow  corresponding  to  the  attachment  of  the  diaphragm.  This 
bow  is  frequently  seen  in  intrathoracic  obstruction.  QZdema  or  sub- 
cutaneous emphysema  occurs  as  indicated  under  general  inspection. 
If  there  is  too  much  fat  over  the  surface  of  the  chest,  the  muscles 
may  be  wanting  in  tone,  and  an  estimation,  therefore,  of  respiratory 
capacity  cannot  be  made.  Wasting  of  the  fat  and  muscles  is  seen  in 
phthisis,  carcinoma,  diabetes,  muscular  atrophy,  and  paralysis.  The 
degree  of  softness  of  the  ribs  can  be  estimated  in  a  measure  by  the 
undue  depression  of  the  ribs  at  the  costo-cartikginous  articulations, 
and  at  the  base  of  the  chest  (about  the  sixth  rib),  during  the  act  of 
inspiration.  It  is  an  indication  of  rickets.  Rigidity  of  the  thorax, 
equal  to  the  senile  fixation,  occurs  in  some  adults  in  middle  life, 
and  Eoberts  points  out  that  in  young  subjects  it  may  be  due  to  con- 
genital syphilis. 

The  Shape  and  Size  of  the  Chest.     We  appreciate  the  shape 
of  the  chest  in  health  by  an  estimation  of  the  relations  of  the  antero- 


FlG. 


Transverse  section  of  healthy  adult  chest  upon  level  of  sterno-xiphoid  articulation. 
Circumference  =  89  centimetres. 


posterior  and  the  transverse  diameters  and  by  the  shape  of  the  trans- 
verse section  of  the  chest.  The- latter  is  an  ellipse,  and  has  been  de- 
scribed as  reniform  (see  Fig.  36).  The  antero-posterior  diameter  is 
about  one-fourth  less  than  the  transverse.  Measurement  with  the  cvr- 
tometer  (see  Mensuration)  verifies  the  result  of  inspection  with  mathe- 
matical precision.  In  children  the  transverse  section  is  different.  It 
is  more  circular,  and  the  antero-posterior  and  transverse  diameters  are 
almost  equal.  (See  Fig.  37.)  Marked  deviations  from  such  section, 
or  in  the  relations  of  the  diameters,  are  seen  in  abnormal  types  of  chest. 
It  is  difficult  to  describe  the  xiutpe  of  the  chest  in  health.  By  re- 
peated practice  we  readily  form  a  judgment  of  the  true  shape.  No 
rule  has  been  applied  to  the  relation  of  the  length  of  the  chest  to  the 
length  of  the  body,  but  it  would  seem  that  there  is  some  such  propor- 
tion (see  Mensuration).  Iu  health  the  chest  should  be  symmetrical, 
the  right  side  probably  a  little  larger  than  the  left.      In  the  ideal  chesl 


238 


SPECIAL  DIAGNOSIS. 


the  muscles  of  respiration  should  be  well  developed  and  there  should  be 
a  moderate  amount  of  subcutaneous  fat.  The  sternum  should  project 
forward  from  above  downward,  and  the  portion  joining  the  manubrium 
and  the  gladiolus    should  be  a  little  more  prominent  than  the  other 


Fig.  36. 


Transverse  section  of  healthy  male  adult  chest.    Semi-circumference,  right  side,  16%  inches  ; 
left  side,  16%  inches  ;  expansion,  3%  inches.    Ward  6,  Philadelphia  Hospital. 

part.  It  is  not  unusual  to  see  a  clearly  marked  demarcation  between 
the  upper  and  middle  portions  of  the  sternum,  or  an  undue  projection 
of  one  or  more  of  the  upper  ribs,  and  some  striking  changes  about 
the  xiphoid  cartilage,  none  of  which  are  indications  of  disease.      The 

Fig.  37. 


Transverse  section  of  an  infant's  chest,  aged  nine  months.     A  circle  within  shows  the  similarity. 

xiphoid  may  be  depressed,  on  account  of  which  a  crater  form  or  funnel- 
shaped  depression  is  seen  (occupation).  The  tip  of  the  cartilage  is 
sometimes  drawn  inward,  but  more  frequently  the  reverse  is  noted. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  239 

The  Movements  of  the  Cheat.  The  frequency,  the  rhythm,  the  degree  of 
expansion,  and  the  so-called  diaphragm-phenomena  are  studied.  A 
complete  respiratory  act  consists  of  two  events,  inspiration  and  expira- 
tion. Inspiration  is  active  ;  expiration  passive.  The  latter  act  is  a 
trifle  longer  than  the  former,  as  may  be  illustrated  by  the  following  pro- 
portion— Insp. :  Exp.  :  :  5  :  6.  A  pause  follows  the  act  of  expiration. 
The  chest  increases  in  circumference  and  in  vertical  length  (descent  of 
diaphragm)  in  inspiration  as  the  lung  expands  with  air.  The  term 
expansion  is  applied  to  the  result  of  inspiration;  its  degree  varies. 

The  frequency  and  character  of  the  movements  in  health  vary  in  the 
two  sexes.  The  respirations  are  from  16  to  24  in  the  minute  in  a 
healthy  adult.  In  the  female  they  may  be  20  to  22.  In  children  the 
frequency  of  respiration  is  much  greater :  under  one  year  44  per  min- 
ute, and  at  five  years  26.  They  are  increased  in  frequency  in  the  stand- 
ing position.  They  are  lessened  in  the  horizontal  position,  increased 
during  bodily  exertion,  with  increased  temperature  of  the  air,  and 
during  digestion.  The  hand  placed  on  the  epigastrium  facilitates  count- 
ing of  the  respirations. 

The  movements  of  the  chest  in  quiet  breathing  are  more  marked  in 
the  lower  half  in  male  adults,  and  thus  the  costo-abdominal  or  dia- 
phragmatic type  of  breathing  is  seen.  The  sternum  rises,  the  ribs  are 
elevated,  and  at  the  same  time  are  drawn  forward  and  outward.  The 
antero-posterior  and  vertical  diameters  increase.  The  costal  angle  and 
epigastric  angle  become  more  obtuse.  The  diaphragm  acts  conjointly 
with  the  external  muscles  of  the  thorax,  and,  as  it  descends,  the  epi- 
gastric region  swells  Avith  each  inspiratory  effort.  In  expiration  the 
sternum  falls,  the  ribs  become  more  slanting  instead  of  horizontal,  the 
epigastrium  retracts,  the  angles  become  acute.  The  antero-posterior 
and  transverse  diameters  lessen.  The  upper  half  of  the  chest  moves 
more  actively  in  women,  and  hence  the  costal  or  upper  thoracic  type  of 
breathing  is  seen.  The  areas  below  the  clavicles  and  the  upper  portion 
above  the  sternum  swell  more  distinctly  during  inspiration.  The  move- 
ments of  the  lower  portion,  and  especially  of  the  diaphragm,  are 
limited. 

The  costal  type  occurs  most  frequently  in  children.  The  type  of 
breathing  is  costal  in  both  sexes  during  sleep;  the  same  type  is  observed 
during  deep  respiration. 

The  diaphragm-phenomena  (Litten).  The  diaphragm  and  walls 
of  the  thorax  approach  each  other  during  expiration,  and  come  in  appo- 
sition at  the  end  of  this  act.  During  inspiration  they  become  separated. 
In  persons  whose  chest-walls  are  not  too  thick  the  movements  of  the 
diaphragm  are  indicated  on  the  surface  by  the  rising  and  falling  of  a 
shadowy  line.  The  patient  must  lie  on  his  back  with  his  face  to  the 
light  and  head  slightly  elevated.  The  observer  stands  a  distance  of 
three  or  four  feet  with  his  back  to  the  light.  The  chest  is  scanned  at 
an  angle  of  about  forty-five  degrees.  In  the  act  of  inspiration  a  hori- 
zontal shadow  or  undulation  is  seen  to  start  on  cither  side  about  the 
sixth  interspace  and  passes  downward  during  inspiration  over  a  distance 
of  two  or  more  interspaces,  and  even  to 'the  margin  of  the  ribs.  In 
expiration  the  shadow  begins  below  and  moves  upward  to  the  starting- 


240 


SPECIAL  DIAGNOSIS. 


point.  It  is  absent  in  all  diseases  which  interfere  with  the  action  of 
the  diaphragm.     It  is  absent  in  pleural  effusions  and  pleural  adhesions. 

The  Shape  and  Size  of  the  Chest  in  Disease.  The  chest 
may  be  enlarged  or  diminished  in  size.  Such  change  may  be  general 
or  bilateral,  unilateral  or  local. 

1.  General  or  Bilateral  Changes  in  Shape.  Enlargement . 
The  "barrel-shaped"  chest,  the  type  of  bilateral  enlargement  of  the 
chest,  is  seen  in  health  when  it  is  in  the  state  of  full  inspiration.      All 

fig.  38. 


Emphysema  with  enlargement  of  the  chest.    The  anteroposterior  diameter  is  muchincreased. 
(Ward  6,  Philadelphia  Hospital.) 

the  diameters  are  increased,  particularly  the  antero-posteri or;  the  length 
is  shortened.  The  diameters  are  almost" equal,  and  the  transverse  sec- 
tion approaches  a  circle.  This  occurs,  because  in  all  figures  of  fixed 
length,  in  order  that  the  area  may  be  increased,  a  change  to  a  circular 
form  must  take  place.  (See  Figs.  38  and  39.)  The  ribs  are  elevated 
and  •  almost  horizontal,  the  epigastric  angle  is  obtuse.  The  sternum 
and  .the  spine  are  arched;  the  former  at  the  angle  of  Ludwig.      The 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


241 


shoulders  are  rounded  and  elevated,  and  the  scapulae  lie  flat  against 
the  thorax.  All  the  muscles  of  respiration  stand  out  prominently, 
the  neck  and  upper  trunk  muscles  particularly.  The  individual  with 
bilateral  enlargement  of  the  chest  presents  a  striking  appearance.  The 
neck  is  short,  the  arms  are  short;  there  is  undue  fulness  above  the 
clavicles.  As  this  enlargement  is  attended  with  dyspnoea,  the  face  is 
drawn  and  anxious,  and  the  lips  usually  faintly  livid,  or  purple. 


Fig.  39. 


Bilateral  enlargement  of  emphysema. 

Inner  line  =  emphysematous  chest. 

Outer  line  =  a  circle  drawn  to  show  how  nearly  the  emphysematous 

approaches  the  circular  shape. 
Dotted  line  =  natural  adult  chest. 


Circumference 
Transverse 
Antero-posterior  = 


Actual  measurement  in  centimetres. 

=  natural   89.0  emphysematous,  87.75. 


29.6 
22.25 


27.25. 
25.4. 


-(Dr.  Gee.) 


The  movement  of  the  chest  in  bilateral  enlargement.  Expansion  is 
lessened.  The  respiratory  capacity  is  diminished.  The  chest  is  in  a 
state  of  full  inspiration,  and  the  attendant  dyspnoea  is  known  as  expira- 
tory dyspnoea.  The  respirations  are  hurried,  the  inspirations  short, 
followed  by  prolonged  expiration.  While  the  expansion  of  the  chest 
in  health  extends  over  an  area  of  three  or  four  inches,  when  the  chest 
is  bilaterally  enlarged  it  may  be  lessened  to  one  and  a  half  inches,  or 
even  be  as  low  as  half  an  inch.  Both  the  costal  and  diaphragmatic  types 
of  breathing  are  seen  in  a  state  of  exaggeration.  In  men  the  diaphragm 
acts  very  vigorously  at  times.  Expiration  is  three  or  four  times  as  long 
as  inspiration. 

Cause.  The  increase  in  size  is  due  to  enlargement  of  the  normal 
contents  of  the  chest,  or  to  the  presence  of  abnormal  contents.  In 
nearly  all  cases  it  is  due  to  an  increased  amount  of  air  within  the 
thorax  (normal  contents),  as  in  emphysema.  In  a  few  instances 
enlargement  of  both  sides  is  seen  in  cases  of  bilateral  pica  ml  effusion, 
but,    as  considerable   effusion    would   be   incompatible   with    life,    the 

16 


242 


SPECIAL  DIAGNOSIS. 


enlargement  from  this  cause  is  never  very  great.  It  is  said  that  such 
enlargement  may  occur  in  rapidly  growing  cancer  of  the  lungs. 

It  must  be  remembered  that  emphysema  can  exist  ■without  bilateral 
enlargement  of  the  chest. 

Bilateral  Diminution  in  Size.  The  type  is  seen  in  the  so-called  phthis- 
ical or  tuberculous  chest.  The  chest  is  long,  the  antero- posterior  diam- 
eter small  (see  Fig.  40),  the  transverse  relatively  very  much  increased. 

Fig.  40. 


15  c 


The  flat  or  phthisical  chest,  short  antero-posterior,  long  transverse  diameter.    (Gee.) 

The  angles  are  acute,  the  ribs  are  slanting,  the  epigastric  angle  is 
particularly  sharp.  The  shoulders  fall,  and  hence  the  scapulae  are 
prominent — so  marked  in  many  cases  that  the  term  alar  or  ' '  winged ' ' 
chest  has  been  given  to  it.  The  anterior  plane  is  often  flattened,  and 
hence  the  term  "flat"  chest  is  employed.  This  change  occurs  because 
the  curve  in  the  cartilage  of  the  true  ribs  becomes  straight.  The  movement 
or  expansion  is  lessened  just  as  the  respiratory  capacity  is  diminished. 

Associated  with  this  type  of  chest  we  see  the  neck  long,  the  larynx 
(Adam's  apple)  very  prominent,  the  arms  long.  The  patient  is 
loosely  put  together;  the  length  of  the  long  bones  is  increased. 

It  is  known  as  the  phthisical,  phthisinoid,  or  tuberculous  chest  (see 
Figs.  41  and  42).  Although  the  term  tuberculous  is  applied  to  the  chest 
of  this  description,  it  does  not  necessarily  imply  that  an  individual  with 
such  a  chest  has,  or  will  have,  tuberculosis.  It  is  true  that  in  individ- 
uals with  such  type  of  chest  the  vulnerability  to  the  action  of  the  tubercle 
bacillus  is  more  marked,  and  they  are  more  liable  to  have  the  disease. 
Nevertheless  a  very  large  number  of  individuals  go  through  life  with 
such  chests  and  die  of  other  diseases.  If  they  are  not  exposed  to  the 
infection,  they  will  certainly  escape  the  disease. 

Cause.  Bilateral  diminution  means  diminution  of  contents.  The 
extent  of  air-surface  is  lessened. 

The  Chest  of  Rhachitis.  Another  type  of  diminished  size  of  chest  is 
constantly  referred  to.  It  is  known  as  theTchest  of  rhachitis  (see  Fig.  43), 
and  arises  in  infancy  on  account  of  this  disease  of  the  bones.  Many 
other  shapes  are  seen  to  which  various  names  have  been  given.  Among 
the  more  common  is  what  is  known  as  the  "  pigeon-breast."  (See  Eha- 
chitis,  and  The  Head.)  The  chest  is  usually  shortened,  the  sternum 
is  much  more  prominent  than  in  health,  the  lower  portion  projecting 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE. 


243 


to  an  unusual  degree.  The  portion  of  the  chest  at  the  junction  of 
the  cartilages  and  the  ribs  is  depressed.  This  tends  to  throw  the  ster- 
num further  outward.  The  transverse  section  of  such  chest  resembles 
a  triangle  with  the  portions  where  the  base-line  joins  the  ribs  rounded. 


Fig.  41. 


Fig.  42. 


The  phthisical  chest.    (Full-blooded  Indian,  Philadelphia  Hospital.) 


(See  Fig.  43.)  The  sternum  is  depressed  and  the  ostco-cartilaginuns 
articulations  arc  more  prominent  in  some  forms  of  rickety  chest.  In 
others  the  ribs  and  sternum  from  above  to  the  fifth  rib  are  prominent, 
and  from  thence  downward  to  the  base  arc  drawn  in.  In  the  chest  of 
rhachitis  the  costal  angle  is  usually  very  acute.  (See  Fig.  44.)  It 
often  looks  as  if  pressure,  as  by  the  hands,  had  been  applied  to  the 
sides  of  the  chest  about  the  anterior  axillary  line,  causing  the  antero- 
lateral portion  to  sink  inward,  while  the  antero-median  portion  is  pro- 
jected forward. 

The  chest  of  rickets  is  attended   by  enlargement  of  the  articulations 


244 


SPECIAL  DIAGNOSIS. 


of  the  cartilaginous  and  bony  portions  of  the  rib — the  rhachitic  rosary 
— and  by  changes  in  the  other  bones. 


Fig.  43. 


Transverse  section  of  a  rhachtic  chest  at  level  of  sixth  thoracic  vertebra. 
32%  inches  ;  right  half,  16%  inches  ;  expansion,  2  inches. 


Circumference, 


The  rhachitie  chest  must  not  be  confounded  with  similar  changes  in 
shape  due  to  abnormal  conditions  of  the  upper  respiratory  apparatus  in 
early  childhood.  In  cases  of  adenoid  disease  of  the  pharynx  (see  Dis- 
eases of  the  Pharynx)  the  change  in  shape  of  the  chest  has  been  noted. 


Fig.  44. 


Fig.  45. 


\\ 


Chest  of  rhachitis.    (Eichhorst.) 


Circumference  =  42.75  centimetres. 
Rickety  chest.     Dotted  line  indicates  the  shape  of 
chest  in  an  infant  about  same  age.    (Gee.) 


The  Transverse  Groove.  This  is  a  depresssion  observed  in  many  in- 
dividuals. It  extends  from  the  median  line  along  the  base  of  the 
thorax  to  the  axilla  ;  its  upper  limit  is  ou  a  level  with  the  xiphoid 
cartilage.      It  slopes  downward  toward    the  axilla.      It  is  caused  in 


DISEASES  OF  THE  LUNGS  AND  PLECI;.!:. 


245 


early  life  by  the  pressure  of  the  external  columns  of  air  on  the  soft 
bouy  thorax  when  the  lungs  are  not  completely  filled  with  air.  Hence 
it  indicates  nasal,  faucial,  or  bronchial  obstruction  in  early  life,  from 
adenoid  disease,  bronchial  catarrh,  or  other  causes.  It  may  mark  the 
upper  limit  of  the  liver  on  the  right  side  as  it  was  in  infancy. 


Fig.  46. 


Unilateral  enlargement  of  chest  (right  side),  artificially  produced  by  injecting  air  into  the  right 
pleural  cavity.  Unbroken  line :  outline  hefore  injection.  Broken  line  :  outline  after  moderate 
distention.  Dotted  line:  outline  after  extreme  distention.  Figures  at  bottom  of  vertical  line 
indicate  the  antero-posterior  diameter ;  along  horizontal  line,  transverse  semi-diameter  ;  remaining 
figures,  right  and  left  semi-circumferences.    (Gee.) 

The  shape  of  the  chest  just  described  (rhachitic)  does  not  indicate 
any  disease  of  the  lungs:  it  does  indicate  deficient  respiratory  capacity, 
and  is,  of  course,  the  tell-tale  by  which  rhachitis  of  early  life,  or  early 
laryngeal  and  nasal  obstruction  are  recognized. 

Unilateral  Changes  in  Shape.  Unilateral  Enlargement.  This 
can  usually  be  seen  more  prominently  at  the  base.  The  length  is 
increased.  The  ribs  are  elevated,  the  side  more  rounded,  the  costal  angle 
more  obtuse.  The  interspaces  are  frequently  effaced,  or  fuller  than  on 
the  corresponding  side.  The  movement  may  be  increased  or  dimin- 
ished, depending  upon  the  cause.  The  nipple  is  displaced  outward. 
The  scapula  of  the  affected  side  is  also  displaced  outward,  and  hence 
the  distance  from  it  to  the  spine  is  greater  than  on  the  opposite  side. 
(See  Fig.  46.) 

Cause.  Enlargement  of  one  side  means  enlargement  of  content-. 
It  may  be  due  (1)  to  increase  of  the  normal  contents,  as  in  compensa- 
tory emphysema,  in  which  there  is  an  increased  amount  of  air  in  the 
lung,  or  (2)  to  the  presence  besides  of  abnormal  contents,  as  fluid  or 
air  in  the  pleural  sac.  It  is  the  most  characteristic  sign  of  pleural 
effusion.  When  the  normal  contents  are  increased  the  movement  is 
increased  ;  when  the  pleural  cavity  is  filled  it  is  diminished. 

Unilateral  Contraction  or  Diminution  in  Size.  The  costal  angles  are 
sharper,  the  plane  of  the  anterior  or  posterior  portion,  or  of  I>"tli,  is 
depressed,  and  approaches  the  transverse  median   plane  of  the  chesl 


246  SPECIAL  DIAGNOSIS. 

(see  Fig.  47).  The  affected  side  looks  flat  before  and  behind.  The 
semi-circumference  is  lessened,  as  well  as  the  diameter  through  the 
nipple  or  any  fixed  point.  The  interspaces  are  lessened  in  width  and 
may  be  drawn  in.  The  ribs  are  closer  together,  and  may  almost 
overlap.     The  movement  of  the  side  is  lessened. 

Fig.  47. 


-75? 

Unilateral  retraction  of  chest,  consequent  upon  cirrhosis  of  left  lung,  in  a  girl  of  fourteen  years. 
The  figures  indicate  antero-posterior  and  transverse  diameters  and  semi-circumferences  of  right 
and  left  half  of  chest.    (Gee.) 

Cause.  Any  diminution  of  contents  will  cause  diminution  of  the 
affected  side.  This  may  occur  from  obstruction  or  compression  of  the 
bronchi  of  that  side  lessening  the  amount  of  air  in  that  portion  of  the 
thorax.  Theoretically  it  may  occur  in  a  case  in  which  there  is  complete 
occlusion  of  the  main  bronchus.  The  condition  is  rare,  and  is  accom- 
panied by  marked  associate  emphysema  of  the  other  lung.  The  unilat- 
eral change  is  most  frequently  seen  in  cases  of  chronic  pleurisy  and 
fibroid  phthisis.  A  large  portion  or  even  the  whole  of  the  lung  may 
be  bound  down  and  compressed  by  thickened  adhesions.  The  pleural 
cavity  of  the  side  thus  affected,  save  where  encroached  upon  by  the 
heart  or  by  invasion  of  an  emphysematous  portion  of  the  lung  of  the 
corresponding  side,  is  completely  obliterated. 

Local  Changes  in  Size  and  Shape.  Enlargement  and  diminu- 
tion are  also  seen. 

Local  Enlargement  is  particularly  noted  in  the  region  of  the  heart 
and  great  vessels,  and  will  be  considered  when  this  divison  of  the  sub- 
ject is  discussed.  A  local  enlargement  in  the  lower  anterior  or  lateral 
region  of  the  chest  may  occur  in  cases  of  empyema,  in  which  the  pus 
tends  to  be  evacuated,  or  in  pulsating  pleurisy.  Enlargement  in  dis- 
eases of  the  mediastinum  is  usually  seen  in  the  region  of  the  heart  and 
vessels,  to  which  reference  must  also  be  made. 

Local  Contraction.  This  may  be  seen  either  at  the  apex  or  the  base. 
At  the  apex  the  local  contraction  or  diminution  in  size  is  seen  above 
and  below  the  clavicle.  The  term  flattening  is  applied  to  this  condition. 
The  interspace  is  sunken  and  the  ribs  depressed.   It  may  be  more  readily 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  247 

seen  when  looked  at  from  behind.  Flattening  may  be  either  in  the 
lateral  or  posterior  region  at  the  base.  The  anterioi\,and  lateral,  or 
the  lateral  and  posterior,  region  is  combined  in  the  local  contraction. 

Cause.  The  physical  condition  of  the  part  is  the  same  as  in  unilat- 
eral or  general  contraction — contraction  or  diminution  in  size  of  the 
parts  underneath.  Anything  which  lessens  the  amount  of  air  in  the 
area  corresponding  to  the  contracted  part  will  cause  local  diminution  in 
size,  or  flattening.  This  is  notably  seen  in  tuberculosis,  in  which  affec- 
tion three  processes,  alone  or  in  combination,  lessen  the  amount  of  air: 
First,  occlusion  of  the  bronchioles  by  tubercles  and  by  inflammatory 
products  causing  collapse  of  the  alveoli ;  second,  the  overgrowth  of  con- 
nective tissue  which  attends  the  more  chronic  forms  of  tuberculosis  ; 
third,  a  localized  pleurisy.  Local  pleurisy,  with  organization  and  con- 
traction of  the  inflammatory  exudate,  also  causes  diminution  of  the 
amount  of  air  underneath  the  part,  or  diminution  of  the  contents  from 
compression  of  the  adjacent  lung  structure.  In  local  contractions 
movement  of  the  part  is  generally  diminished. 

General  Review.  It  must  not  be  forgotten  that  in  all  these  changes 
in  shape  and  size  of  the  chest,  with  the  exception  of  unilateral  enlarge- 
ment, the  element  of  time  is  necessary  to  produce  them.  In  emphy- 
sema the  change  in  shape  takes  a  long  time  to  develop.  The  unilateral 
and  local  contractions  just  spoken  of  also  make  sIoav  progress,  and  hence, 
it  must  follow,  require  more  or  less  chronic  disease  for  their  develop- 
ment. The  occurrence  of  pleural  effusion  may  cause  unilateral  en- 
largement very  rapidly. 

The  Movements  of  the  Chest  in  Disease.  Bilateral  Changes. 
Frequency.  The  movements  are  increased  in  nearly  all  forms  of  dysp- 
noea. (See  Dyspnoea.)  The  frequency  of  movement  varies  in  many 
affections.  They  are  more  markedly  increased  in  the  acute  lung  affec- 
tions attended  by  fever,  and  are  especially  more  rapid  in  children. 
Increased  frequency  of  respiration  does  not  necessarily  indicate  pul- 
monary disease.  It  is  always  seen  in  fever,  and  is  a  marked  phenom- 
enon of  hysteria.  Conditions  outside  of  the  chest  increase  the  frequency, 
as  enlargement  of  the  abdomen  from  any  cause  encroaching  upon  the 
capacity  of  the  chest.  The  respirations  are  lessened  in  frequency  in 
cases  of  disease  of  the  medulla  in  which  there  is  pressure  upon  the 
respiratory  centre,  and  in  some  forms  of  poisoning,  as  that  due  to 
opium. 

Alterations  in  the  Rhythm  of  Movement.  Alterations  in  the  character 
and  rhythm  of  the  movement  are  observed  by  inspection.  (See  Dysp- 
noea.) The  movements  may  be  (1)  slow,  and  either  shallow  or  deep  ; 
(2)  rapid  and  shallow  or  deep  ;  (3)  irregular  in  rhythm.  The  relations 
of  the  act  of  inspiration  to  that  of  expiration  in  health  is  as  5  to  6  ;  in 
women,  children,  and  the  aged,  6  to  8.  The  expiration  is  longer.  The 
expiration  maybe  prolonged,  so  that  it  is  far  greater  in  length  than  in- 
spiration. Length  of  inspiration  increased.  The  degree  of  expansion 
and  the  duration  of  inspiration  arc  increased  when  there  is  obstruction  in 
the  trachea  or  larynx.  Such  increased  expansion  of  the  upper  chest  is 
usually  associated  with  retraction  of  the  soft  parts  of  the  thorax,  espe- 
cially at  the  base.     The  ribs  and  the  tissues  along  the  margins  of  the 


248  SPECIAL  DIAGNOSIS. 

thorax  are  drawn  in  with  each  inspiration.  The  space  occupied  by 
the  lung  above  the  clavicle  niay  also  be  retracted.  The  transverse 
groove  is  more  pronounced.  If  the  difficulty  in  breathing  continues, 
the  indrawing  becomes  very  marked,  and,  if  the  ribs  are  soft,  perma- 
nent. Expiration  prolonged.  Inspiration  is  short  and  quick  in  cases 
of  emphysema.  The  expiration  is  correspondingly  prolonged,  and  the 
muscles  of  expiration  are  seen  to  be  brought  into  full  action. 

In  the  consideration  of  dyspnoea  we  shall  describe  the  appearance 
and  posture  of  the  patient,  and  the  action  of  the  muscles  of  respiration 
(see  Subjective  Symptoms). 

Irregular  Rhythm.  By  inspection  the  Cheyne-Stokes  type  of  breath- 
ing can  be  noted.  ' '  Respiratory  pauses ' '  of  half  to  three-quarters  of 
a  minute  alternate  with  a  short  period  of  increased  activity,  and  during 
this  time  twenty  to  thirty  respirations  occur.  The  respirations  consti- 
tuting this  series  are  shallow  at  first,  but  gradually  they  become  deeper 
and  more  dyspnceic,  and  finally  become  shallow  or  superficial  again. 
The  acts  of  respiration  are  carried  on  by  an  alternation  of  pauses  and 
periods  of  modified  breathing.  Sometimes  consciousness  is  abolished 
during  the  pause.  Often  the  pupils  are  contracted  and  inactive.  "When 
the  respirations  begin  they  dilate. 

Unilateral  Changes  in  Movement.  Increased  Movement  of  one  side 
is  seen  when  the  lung  of  that  side  is  acting  vigorously  from  compensa- 
tion, the  other  lung  being  disabled  by  disease.  The  whole  side  moves 
more  rapidly  and  vigorously.  The  increased  movement  is  associated 
with  enlargement  of  the  affected  side  and  hyper-resonance  on  percussion. 
Unilateral  diminution  in  movement  occurs  when  there  is  diminution  of 
the  respiratory  surface,  occlusion  of  the  bronchial  tubes,  or  from  causes 
outside  of  the  lung.  The  air-space  is  lessened  in  cases  of  pneumonia, 
tuberculosis,  or  any  affection  which  fills  bronchioles  and  alveoli  with 
inflammatory  exudation  or  fluid.  The  air  space  is  particularly  lessened 
by  the  compression  of  effusions  in  the  pleura,  of  contracted  and  thick- 
ened exudations,  and  of  adhesions. 

Impaired  motion  due  to  "pleural  effusion  is  almost  always  unilateral, 
develops  gradually,  following  an  attack  of  acute  pleurisy,  is  unattended 
by  pain  on  respiration,  but  is  attended  frequently  by  great  embarrass- 
ment of  the  respiration,  and  sometimes  by  orthopncea.  Fever  is  usually 
moderate  in  uncomplicated  cases.  It  is  to  be  recognized  by  the  clinical 
signs  mentioned  and  by  the  physical  signs  of  fluid  in  the  pleura. 

Impaired  motion  from  chronic  pleurisy  is  of  long  standing  and  grad- 
ual development.  The  chest-wall  upon  the  affected  side  is  retracted,  and 
may  be  very  markedly  sunken.  In  the  absence  of  accompanying  lung 
trouble  there  is  no  pain  and  no  fever.  It  is  to  be  distinguished  from 
other  types  of  impaired  motion  by  the  sinking  in  of  the  affected  side, 
in  sharp  contrast  with  the  hypertrophy  of  the  other  side  ;  by  the 
absence  of  fever  and  pain  ;  by  its  chrouicity  ;  and  by  the  physical 
signs  of  thickened  pleura  and  compressed  lung.  Impaired  motion 
from  pneumothorax  develops  suddenly,  generally  in  a  person  with 
tuberculosis  of  the  lungs.  Its  appearance  is  usually  precipitated  by 
coughing,  and  its  sudden  development  is  marked  by  intense  pain,  dis- 
tention of  the  affected  side,  great  difficulty  in  breathing,  and  a  very 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  249 

anxious  expression  of  countenance.  The  escape  of  air  into  the  pleural 
cavity  is  followed  by  the  development  of  pleurisy  with  effusion,  so  that  the 
affection  presents  the  physical  signs  of  air  and  fluid  in  the  pleural  cavity. 

The  motion  of  the  affected  side  is  sometimes  impaired  in  'pneumonia , 
when  a  large  portion  or  the  whole  of  one  lung  is  involved,  and  the  air- 
vesicles  are  so  occluded  that  very  little  air  can  get  in.  The  physical 
signs  in  these  cases  resemble  those  of  pleurisy  with  effusion  very  closely, 
but  the  diagnosis  can  be  made  by  noting  the  acute  onset  of  the  disease, 
with  high  temperature  and  frecuient  respiration,  without  antecedent 
pleurisy,  and  by  the  presence  of  cough  with  expectoration  containing 
the  pneumococcus. 

Occlusion  of  the  bronchus,  with  diminution  of  the  movement  of  the 
corresponding  side,  is  seen  in  rare  cases  in  which  a  foreign  body  fills 
the  lumen  of  the  tube,  or  in  more  common  cases  of  pressure  externally 
upon  the  bronchus  by  an  aneurism  or  mediastinal  tumor. 

Impaired  motion  from  pressure  on  a  bronchus  by  an  aneurism  or  en- 
lai'ged  lymph-gland  produces  the  physical  signs  of  collapse  of  the  lung, 
coupled  with  those  peculiar  to  the  cause  of  the  occlusion  of  the  bron- 
chus.     It  develops  gradually,  the  patient  having  no  pain  in  the  lung. 

Outside  of  the  lung  lessened  movement  is  caused  by  (1)  interference 
with  the  muscular  activity  of  that  side  from  rheumatism  of  the  intercostal 
or  respiratory  muscles;  (2)  pain  seated  either  in  the  ribs  or  in  the  pleura. 
It  may  be  due  to  acute  pleurisy,  the  patient  checking  the  motion  of 
the  affected  side  as  much  as  possible,  and  breathing  with  the  abdominal 
muscles,  because  chest  respiration  causes  acute  pain.  Impaired  motion 
from  this  cause  or  from  pleurodynia  may  be  suspected  when  it  has 
come  on  suddenly,  and  when  respiration  causes  acute  suffering,  usually 
depicted  in  the  face.  Pleurodynia  and  pleurisy  are  to  be  distinguished 
from  each  other  by  the  presence  in  the  one  case  of  tender  muscles,  a 
more  constant  and  less  stabbing  pain,  and  absence  of  fever;  cough,  and 
rales;  and,  in  the  case  of  pleurisy,  by  the  occurrence  of  stabbing  pain 
in  respiration,  absence  of  local  tenderness,  and  presence  of  fine,  dry, 
or  coarse  rales  on  inspiration,  with  cough  and  fever. 

Local  diminution  of  the  movement  or  deficient  expansion  occurs 
under  the  same  conditions  that  produce  flattened  and  local  contraction, 
and  for  the  same  reason.  Hence  deficient  expansion  is  observed  in  the 
early  stages  of  phthisis,  or  in  local  pleurisies. 

Impaired  motion,  due  to  consolidation  of  the  lung  in  tuberculosis,  is 
usually  limited  to  one  of   the  apices,  and  is  accompanied  by  flattening 
of  the  affected  apex  and  emaciation.     The  condition  is  of  gradual  devel- 
opment, and  presents  the  usual  signs  of  tubercular  consolidation  of  tin 
lungs  (q.  v.). 

Sometimes  the  impaired  motion  and  flattening  are  due  to  a  superficial 
cavity  from  tuberculosis  or  abscess,  and  when  the  walls  are  very  thin 
they  may  be  seen  to  flap  feebly  with  respiration. 

Rarer  causes  of  impaired  motion  of  the  lung  are  cancer  and  hydatid 
cyst  (q.  v.). 

Palpatio^.  By  palpation  the  results  of  inspection  are  confirmed, 
the  character  and  consistence  of  tumors  ascertained,  the  vocal  fremitus 
determined,  and  fluctuation  detected. 


250  SPECIAL  DIAGNOSIS. 

Method.  The  surface  should  be  bared,  although  the  fremitus  can  be 
detected  through  a  thin  layer  of  linen  or  gauze.  To  detect  the  fremitus 
in  front,  it  is  often  well  to  stand  behind  the  patient,  with  the  palms 
of  the  hands  placed  over  the  surface  of  the  chest  in  front.  The  oppo- 
site position  is  taken  to  detect  the  fremitus  behind.  The  axillary 
region  must  also  be  investigated.  The  hands  should  be  warmed  and 
applied  evenly  to  the  surface.  The  two  sides  must  constantly  be  com- 
pared, either  by  simultaneous  application  of  the  hands  on  the  two  sides, 
or  by  applying  the  hand  first  on  one  side,  then  on  the  other. 

Cause.  The  columns  of  air  in  the  bronchial  tubes  are  thrown  into 
vibration  during  the  act  of  speaking.  The  vibrations  are  transmitted 
to  the  hand  on  the  surface  of  the  chest.  They  are  known  as  the  vocal 
fremitus.  In  infants  the  cry  must  be  relied  upon  instead  of  the  spoken 
voice. 

Vocal  Fremitus  in  Health.  The  fremitus  on  the  right  side  at  the 
apex  is  stronger  than  on  the  left,  because  the  right  bronchus  is  larger 
than  the  left,  its  angle  with  the  trachea  is  more  acute,  and  the  bron- 
chus going  to  the  right  upper  lobe  is  two  and  one-half  inches  nearer 
the  larynx  than  the  left  (Cary,  Ewart).  The  fremitus  is  stronger  in 
persons  with  deep,  low-pitched  voices,  because  the  vibrations  are  not  so 
rapid.  It  is  more  distinct,  therefore,  in  males  than  in  females,  and  in 
individuals  with  a  base  voice.  The  vocal  fremitus  is  felt  more  dis- 
tinctly in  persons  with  thin  chest-walls.  Thick  chest-walls  and  large 
mammary  glands  interfere  with  the  transmission  of  fremitus.  The 
fremitus  is  not  distinct  in  children  because  the  vibrations  are  too  rapid. 

It  is  well  to  become  familiar  with  the  vibrations  produced  by  fixed 
monotones  in  order  to  appreciate  the  fremitus.  The  patient  is  asked 
to  count  one,  two,  three,  or  to  repeat  ninety-nine  three  or  four  times. 
It  is  well  to  observe  a  fixed  rule  as  to  the  words  used,  in  order  to  have 
definitely  in  the  mind  the  character  of  the  vibrations  in  health,  and 
the  departures  from  the  normal  in  disease. 

Vocal  Fremitus  in  Disease  The  vocal  fremitus  may  be  in- 
creased, may  be  diminished,  or  may  be  absent  entirely. 

Vocal  Fremitus  Increased.  When  the  lung  is  consolidated,  vibra 
tions  are  transmitted  to  the  hand  with  greater  force.  Fremitus  is 
increased  in  all  consolidations,  as  in  pneumonia,  tuberculosis,  and  hem- 
orrhagic infarct.  (See  Fig.  48.)  The  fremitus  may  be  absent  in  rare 
cases  of  pneumonia,  in  which  the  large  tubes  are  occluded  by  exudate. 
The  fremitus  is  increased  in  the  later  stages  of  tuberculosis,  when  cavi- 
ties have  formed,  if  the  walls  are  dense. 

Vocal  Fremitus  Diminished.  Anything  intervening  between  the  lung 
and  the  surface  of  the  chest  which  interferes  with  the  conduction  of 
the  vibrations  diminishes  the  fremitus.  The  fremitus  is  diminished 
in  cases  of  thickened  pleura,  and  in  thin  layers  of  pleural  effusion. 
The  fremitus  is  lessened  if  the  columns  of  air  in  the  bronchi  are  smaller 
on  account  of  diminution  in  the  calibre,  as  in  bronchitis  or  in  emphy- 
sema and  asthma.  The  fremitus  is  lessened  in  cavities  filled  with  fluid, 
or  when  the  bronchus  is  occluded. 

Vocal  Fremitus  Absent.  1.  The  vocal  fremitus  is  absent  when  the 
columns  of  air  are  obstructed  entirely  by  occlusion  of  the  bronchus, 


DISEASES  OF  THE  LUNGS  AND  PLEVR2E. 


251 


as  by  the  external  pressure  of  a  tumor,  aneurism,  or  enlarged  gland. 
2.  The  fremitus  is  absent  in  accumulations  in  the  pleura  of  air  or  of 
fluid,  causing  interference  with  the  vibrations.  (See  Fig.  49.)  The 
well-known  illustration  of  striking  a  stone  underneath  the  surface  of 
the  water  applies.  If  the  ear  of  the  listener  is  above  the  water,  the 
sound  cannot  be  heard.  If  the  ear  is  underneath  the  water,  the  sound 
is  heard  a  long  distance  from  its  origin.  Vocal  fremitus  is  absent 
in  pneumothorax,  in  hydrothorax,  in  pyothorax,  and  in  hemothorax. 
The  same  physical  condition  is  present  when  the  pleura  is  greatly  thick- 
ened, and  hence  the  fremitus  is  also  absent. 


Fig.  49. 


Consolidation  :  Pneumonia.    Vocal  fremitus 
increased.    (Gibson  and  Russell.) 


Pleural  effusion.    Vocal  fremitus  absent 
at  a.    (Gibson  and  Russell.) 


The  vibrations  produced  by  the  passage  of  air  through  mucus  or 
fluid  in  the  bronchial  tubes  are  transmitted  to  the  hand  when  it  is  laid 
on  the  surface  of  the  chest.  They  are  known  as  rhonchial  fremitus. 
They  are  felt  during  inspiration.  They  may  be  felt  all  over  the  chest 
in  bronchitis,  or  in  asthma,  as  distinct  vibrations,  sometimes  coarse, 
or  again  fine,  indicating  rapidity  of-  movement.  The  vibrations  may 
be  transmitted  over  a  localized  area  in  phthisis,  due  to  air  passing 
through  fluid  in  the  cavity.  They  are  distinct  in  children  in  cases  of 
bronchitis,  and  are  often  the  source  of  much  alarm  to  the  parents. 

Friction-fremitus.  An  exudation  of  lymph  on  the  surface  of  the 
pleura  often  causes  a  vibration  which  may  be  transmitted  to  the  hand. 
It  is  known  as  a  friction-fremitus,  and  is  felt  in  inspiration.  It  is 
usually  felt  at  the  base  of  the  chest,  in  front,  laterally,  or  posteriorly. 
It  is  not  modified  by  coughing,  and  is  increased  by  full  breathing. 
The  rhonchi,  on  the  other  hand,  arc  influenced  by  cough  and  breathing. 

Fluctuation  is  detected  by  palpation  in  some  cases  of  effusion,  par- 
ticularly if  the  intercostal  spaces  are  swollen  and  tense,  or  if  an 
empyema  is  about  to  point.  In  rare  instances  it  may  be  detected  by 
striking  the  chest  opposite  the  palpating  hand. 


252  SPECIAL  DIAGNOSIS. 

Percussion.  By  percussion,  (1)  sounds  are  elicited,  (2)  the  degree 
of  resistance  to  the  percussing-finger  estimated.  When  a  part  is  per- 
cussed the  sounds  produced  are  noises  or  tones.  If  a  tone,  the  vibra- 
tions are  uniform  and  will  be  in  unison  with  a  tuning-fork  ;  if  a  noise, 
the  vibrations  produced  are  without  uniformity.  We  speak  of  the  pitch, 
the  volume,  the  duration,  and  the  quality  of  the  sound.  The  pitch 
depends  upon  the  rapidity  of  vibrations,  the  number  that  occur  in  a 
definite  period  of  time.  It  may,  therefore,  be  high  or  low.  In  sounds 
that  are  high  in  pitch  the  vibrations  are  rapid.  In  sounds  that  are 
low  in  pitch  the  vibrations  are  correspondingly  slower  in  the  same 
period  of  time.  The  volume  or  intensity  of  the  sound  depends  upon 
the  amplitude  of  the  vibrations,  and  varies  directly  as  the  square  of 
the  amplitude.  It  is  modified  by  the  degree  of  force  used  in  the  pro- 
duction of  the  sound.  "Duration"  explains  itself.  These  charac- 
teristics bear  certain  relationships.  Sounds  that  are  high  in  pitch  are 
of  diminished  volume  or  intensity  and  of  short  duration.  The  accom- 
panying diagram  shows  the  relation  of  the  characters  of  the  sound. 
(See  Fig.   50.)     On  the  other  hand,  sounds   that  are  low  in  pitch 

Fig.  50. 


Flatness. 

Dull  tone. 

Tracheal  or  tubular  tone. 
Resonant  tone. 


Tympanitic  tone. 


Volume  and  duration. 


Diagrammatic  sketch  of  the  relations  of  the  character  of  tone.    The  perpendicular 
line  represents  the  pitch.    The  transverse  line  the  volume  and  duration. 

have  correspondingly  greater  volume  or  intensity  and  longer  dura- 
tion. The  three  characteristics  determine  the  quality  of  the  sound. 
The  term  "  clearness"  is  applied  to  sounds  which  have  the  character 
of  tones.  They  are  low  in  pitch,  of  good  volume,  and  long  duration. 
Sounds  that  are  high  in  pitch,  of  small  volume,  and  short  duration, 
are  of  a  dull  quality.  Xoises,  highest  in  pitch  and  least  in  volume 
and  duration,  are  absolutely  dull  or  flat.  The  former  are  indicative  of 
the  presence  of  air  ;  the  latter,  of  the  absence  of  air..  The  tones,  or 
clear  sounds,  are  naturally  produced  over  structures  containing  air. 
The  production  of  a  tone  implies  the  presence  of  air  in  a  sac.  Struc- 
tures in  which  the  proportion  of  air  to  solid  material  varies  yield 
sounds  which  vary  between  clearness  and  muffling  to  absence  of  tone 
or  dulness.  Resonance  and  tympany  are  clear  sounds  which  will  be 
explained  later. 

Method  of  Procedure.  Due  attention  should  be  paid  to  the  presence 
or  absence  of  tenderness,  which  necessarily  modifies  the  results  obtained 
by  this  method  of  exploration.     Definite  information  can  be  secured 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  253 

by  light  percussion,  even  when  there  is  a  good  deal  of  tenderness.     In 
children  percussion  should  be  the  final  step  in  the  examination. 

Immediate  Percussion.  The  chest  may  be  tapped  by  the  ringer  or 
hand  directly.  This  was  the  original  method  of  percussing  the  chest ; 
but  is  not  now  in  vogue,  except  when  the  clavicles  and  surface  of  the 
sternum  are  percussed.     It  was  known  as  the  immediate  method. 

Mediate  Percussion  The  method  now  employed  is  that  in  which 
a  medium  is  placed  between  the  chest-wall  and  the  instrument 
used  for  percussing.  This  medium  is  called  a  pleximeter.  It  may 
be  a  small  plate  of  ivory  of  suitable  size  to  place  between  the  ribs, 
or,  better  still,  the  fingers  of  the  hand  not  used  in  tapping.  The  plessor 
is  used  to  create  the  sound.  It  may  be  a  small  hammer.  The  one 
usually  selected  is  of  moderate  weight,  has  a  firm,  light,  slightly  flex- 
ible handle  and  a  metal  head,  the  poles  of  which  are  tipped  with  rubber. 
For  purposes  of  class  demonstration  a  plessor  of  this  character,  with 
an  ivory  pleximeter,  is  of  value ;  but  for  bedside-work  the  fingers  of 
the  physician  are  better. 

The  Use  of  the  Pleximeter.  The  pleximeter  must  be  placed  in  close 
contact  with  the  surface  of  the  chest  in  performing  percussion.  If 
the  finger  is  used  as  a  pleximeter,  in  percussing  the  anterior  portion  of 
the  chest,  for  instance,  it  must  be  placed  parallel  with  the  ribs.  It 
must  not  cross  them.  If  it  is  not  in  close  contact  with  the  chest,  the 
cushions  of  air  between  the  two  will  modify  the  sound,  so  that  accurate 
data  are  not  obtained.  Interspace  after  interspace  should  be  percussed 
in  this  manner  from  above  downward.  At  the  same  time,  if  neces- 
sary, the  pleximeter  may  be  placed  over  the  corresponding  ribs,  but 
parallel  with  them.  With  a  little  practice  the  method  of  applying  the 
pleximeter  can  soon  be  acquired. 

The  Use  of  the  Plessor.  This  requires  considerable  practice  on  the 
part  of  the  student.  If  a  metal  instrument  is  used,  care  should  be 
taken  to  acquire  the  habit  of  percussing  under  all  circumstances  with 
the  same  degree  of  force.  If  the  finger  of  the  operator  is  employed  as 
a  plessor,  several  points  in  the  procedure  must  be  remembered.  It  is 
better  to  use  one  finger,  preferably  the  middle  finger.  Some  operators 
use  more  than  one  finger,  but  with  a  little  practice  a  sufficient  degree  of 
force  can  be  given  with  one  to  elicit  the  sounds  essential  for  distinction. 
The  finger  should  be  bent  at  right-angles  and  kept  in  a  fixed  position. 
It  must  be  made  to  strike  the  pleximeter  perpendicularly  to  its  plane. 
If  the  blow  is  given  at  any  other  angle  to  the  part  percussed,  a  true 
sound  cannot  be  obtained.  The  blows  must  be  regular  and  the  force 
even.  The  character  of  the  part  investigated  will  determine  the  degree 
of  force  that  should  be  used.  The  force  of  the  blow  is  to  come  from 
the  wrist  alone,  neither  the  arm  nor  the  forearm  must  come  into  play. 
Beginning  anteriorly  with  the  supra-clavicular  fossae,  and  proceeding 
downward  an  interspace  at  a  time,  comparison  should  be  made  with 
the  other  side  at  each  step.  The  axillary  portions,  and  the  posterior 
portions  from  supra-spinous  fossae  to  base,  should  then  be  examined  in 
the  same  way.  Recapitulation:  Apply  the  pleximeter  closely  i<»  the 
surface  parallel  with  the  ribs  or  interspaces.  Do  not  apply  unci-  rib 
and  interspace  at  the  same  time.     Strike  first  with  one  finger,  which 


254  SPECIAL  DIAGNOSIS. 

is  bent  at  a  direct  right-angle.  Let  it  fall  perpendicularly  on  the  plex- 
imeter.  Let  the  blows  be  of  equal  force  and  in  rhythmical  succession. 
Let  the  force  of  the  blow  come  from  the  wrist.  Always  compare  the  two 
sides  of  the  chest,  and  first  percuss  the  side  presumably  normal.  The 
arm  certainly,  and  the  forearm  as  much  as  compatible  with  wrist-move- 
ment, should  be  kept  fixed. 

Position  of  the  Patient.  The  best  position  is  the  standing  one,  with 
the  arms  allowed  to  drop  loosely  at  the  sides,  the  head  straight,  not 
thrown  back,  and  the  shoulders  allowed  to  fall  a  little  forward  if  they 
are  inclined  to  do  so.  Any  position  which  throws  the  chest  muscles 
into  contraction  tends  to  defeat  the  object  of  the  examiner  who  seeks 
to  elicit  the  chest-sounds.  In  percussing  the  posterior  portions  of  the 
chest  it  is  desirable  to  have  the  patient  stoop  forward  with  arms  folded. 
While  this  renders  the  muscles  more  tense,  it  has  the  advantage  of 
exposing  a  larger  portion  of  the  chest. 

When  the  patient  is  confined  to  bed  he  should,  if  not  too  ill,  be 
allowed  to  sit  up  during  percussion,  as  contact  with  the  bed  or  with 
pillows  deadens  the  sounds  elicited.  This  fact  should  be  borne  in  mind 
when  from  any  cause  it  is  not  desirable  to  have  the  patient  sit  up. 

All  clothing  should  be  removed,  if  possible.  A  thin  undershirt  may 
be  permitted  from  motives  of  delicacy,  or  parts  only  of  the  chest  be 
exposed  at  one  time  if  there  be  danger  of  chill. 

The  Sounds  in  Health.  Four  types  of  sounds  can  be  produced 
by  percussing  over  the  trunk  for  the  purpose  of  study.  1.  Tympany 
over  the  caecum.  2.  Resonance  over  the  lungs.  3.  Tubular  or  tracheal 
sound  over  the  trachea.  4.  Dulness  over  the  heart.  Modifications  of 
these  types  represent  all  sounds  produced  under  every  variety  of  cir- 
cumstances. They  will  be  considered  in  the  order  of  their  importance. 
The  term  resonance  is  applied  to  the  clear  sound  that  is  produced  over 
the  lungs  on  percussion.  It  is  due  to  the  vibration  of  the  chest-walls 
and  of  the  air  in  the  bronchi.  ''Pulmonary  resonance "  is  a  term 
also  used  to  indicate  the  same  sound.  While,  as  stated  above,  the 
sound  produced  is  called  a  tone,  yet  on  account  of  the  relation  of  the 
air  to  the  solid  structure  of  the  lung,  the  air  being  confined  in  innu- 
merable sacs,  a  true  tone  is  not  produced — i.e.,  the  sound  cannot  be 
pitched  with  another  tone  or  made  to  vibrate  in  unison  with  one.  For 
practical  purposes,  however,  the  term  "  tone"  may  be  used  converti- 
ble with  "  clearness"  and  "resonance."  Its  characteristics  cannot 
be  defined  accurately,  and  must  be  learned  by  repeated  practice. 

Modifications  in  Health.  The  degree  of  clearness  or  resonance  differs 
in  various  parts  of  the  thorax.  It  is  purer  in  the  upper  axillary 
region,  at  the  angle  of  the  scapula  behind,  and  on  the  anterior  surface 
of  the  chest,  in  the  second  interspace.  It  is  slightly  higher  in  pitch 
at  the  right  than  at  the  left  apex.  It.is  modified  by  the  condition  of 
the  chest-walls.  Thick  chest-walls,  accumulations  of  fat,  the  mam- 
mary gland,  and  the  scapulae  impair  the  resonance  and  necessitate  deep 
percussion  to  bring  out  the  true  sounds.  In  persons  with  thin  chest- 
walls  the  resonance  is  clear  and  more  pronounced.  The  elasticity  of 
the  chest-walls  also  modifies  it.  In  the  aged  it  is  less  clear  because  of 
rigid  chest-walls.      In  children,  in  whom  the  chest-walls  are  elastic, 


DISEASES  OF  THE  LUNGS  AND  PLEUEJS.  255 

the  resonance  is  much  fuller  or  clearer,  and  approaches  more  nearly  the 
character  of  a  tone.  The  sounds  vary,  within  certain  limits,  in  different 
individuals  with  perfectly  healthy,  normal  chests,  as  may  be  seen  from 
the  above.  Moreover,  a  sound  normal  in  one  part  of  the  chest  may, 
in  another  part,  indicate  disease.  It  follows  that  percussion- sounds 
do  not  have  an  absolute  value;  their  significance  depends  upon  the 
individual  and  upon  the  part  of  the  chest  examined.  The  student 
should  learn  from  the  outset  to  compare  the  sounds  developed  by  per- 
cussion of  symmetrical  portions  of  the  chest,  and  thus  determine  the 
normal  for  the  individual.  Below  the  third  rib  on  the  left  side  the 
dulness  of  the  heart  destroys  the  value  of  comparative  percussion. 
Significance:  Excess  of  clearness  or  resonance — hyper-resonance — 
means  excess  of  air,  as  in  vicarious  emphysema.  Diminution  of  clear- 
ness means  diminution  of  air — increase  of  solid  structure. 

Abnormal  changes  in  resonance  caused  by  disease  will  be  considered 
later. 

The  tracheal  tone  is  a  clear  tone  produced  over  the  trachea  when 
the  mouth  is  open  moderately.  It  is  clear,  higher  in  pitch  than 
resonance,  and  may  be  of  a  tubular  quality. 

Tympany.  When  a  single  cavity  with  smooth  walls,  containing 
air,  is  percussed,  the  sound  that  is  produced  is  a  tone  of  low  pitch,  of 
considerable  volume  or  intensity  and  of  long  duration.  The  term 
"  tympany"  is  applied  to  this  sound.  In  health  it  can  be  elicited 
over  the  stomach  when  it  is  free  from  food,  over  the  large  intestine,  and 
at  times  over  the  small  intestine.  In  addition  to  the  low  pitch  and 
large  volume,  it  possesses  a  peculiar  metallic  quality  which  is  character- 
istic. It  may  be  said  to  be  a  "  hollow"  sound.  It  is  a  quality  of  sound 
with  which  the  student  should  become  familiar,  for  variations  are  char- 
acteristic of  abnormal  physical  conditions  in  the  lung  and  in  the  abdo- 
men. It  must  be  remembered  that  tympany  can  be  developed  normally 
over  the  posterior  portions  of  the  lungs  of  infants  and  children.  The 
relation  of  this  sound  to  resonance,  or  the  sound  produced  on  percussing 
the  healthy  lung,  and  to  dulness  produced  over  airless  structures  may 
be  appreciated  by  reference  to  the  diagram  modified  from  Gee.  (Fig.  50.) 
In  pitch,  in  volume,  and  in  duration  it  is  lower  than  the  resonant  and 
tracheal  tones.  The  latter  stands  midway  between  tympany  and  dulness. 
As  intimated  previously,  all  varieties  of  sounds  that  may  be  produced, 
and  which  occupy  positions  between  the  extremes  noted  in  the  triangle, 
are  dependent  entirely  upon  the  proportion  of  air  to  solid  material. 

Dulness.  The  sound  over  the  heart  is  dull,  and  may  be  useful  to 
compare  with  dull  sounds  yielded  over  areas  usually  resonant.  If  a 
dull  sound  has  some  pitch  and  duration,  some  tone  is  mingled  with  it. 
If  dulness  is  absolute,  it  is  without  pitch  and  is  a  noise.  The  signifi- 
cance of  dulness  has  been  described  :  it  means  the  absence  of  air. 

The  Pitch.  The  estimation  of  the  pitch  of  the  sound  is  of  the  highesf 
importance.  It  is  the  one  distinctive  attribute  or  characteristic  which 
is  of  special  diagnostic  significance  as  to  the  physical  condition  of  the 
part.  It  requires  considerable  practice  to  estimate  it  correct  v.  [ts 
significance  in  relation  to  dulness  and  tympany  has  been  mentioned. 
Although  a  high-pitched  sound  may  be  considered  a  dull  sound,  this 


256  SPECIAL  DIAGNOSIS. 

is  not  necessarily  so.  A  sound  of  high  pitch  need  not  be  markedly 
dull,  indeed  it  may  be  moderately  clear.  Under  the  right  clavicle  in 
health  the  pitch  is  higher  than  under  the  left,  but  not  dull  in  character. 

The  student  may  become  familiar  with  the  pitch,  and  with  altera- 
tions in  it,  by  percussing  over  a  portion  of  the  lung  clearly  resonant, 
as  in  the  third  interspace  and  thence  doAvnward  on  the  right  side.  As 
the  interspaces  in  apposition  with  the  liver  are  reached  the  pitch 
changes.  The  fulness  of  the  sound  is  lessened  ;  it  becomes  more 
shallow.  The  increase  in  rapidity  of  the  vibrations  can  almost  be 
appreciated,  and,  as  they  increase,  the  heightened  pitch  caused  by  them 
is  recognized.  This  normal  increase  in  pitch  is  due  to  a  thin  layer  of 
lung  backed  up  behind  by  the  solid  liver.  Change  in  pitch  makes  it 
possible  to  outline  organs  and  pursue  topographical  percussion. 

The  Degree  of  Kesistance.  This  is  estimated  by  the  sense  of 
touch.  When  organs  containing  air  are  percussed  the  resistance  appre- 
ciated by  the  finger  percussed  is  small,  or,  indeed,  may  be  said  to  be 
absent  entirely.  The  sensation  of  the  finger  is  as  if  the  parts  under- 
neath bounded  away.  When  the  air  decreases  and  the  proportion  of  solid 
structure  increases  more  resistance  is  felt.  It  is  of  the  greatest  impor- 
tance carefully  to  educate  the  finger  in  this  sense  of  resistance.  It  is 
often  difficult  to  determine  the  pitch  exactly,  and  the  sense  of  resistance 
furnishes  an  additional  means  of  detecting  the  presence  or  absence  of 
solid  structure. 

Superficial  and  Deep  Percussion.  In  superficial  percussion  the 
blows  are  directed  lightly  over  the  part  percussed,  so  as  to  bring  out  the 
sound  yielded  by  the  portion  directly  underneath  the  surface.  Hence 
superficial  percussion  is  applicable  over  the  thinner  portions  of  the 
lung.  Light  percussion  is  necessary  in  children  and  in  patients  with 
sore  chest- walls,  or  when  they  have  just  had  a  hemorrhage.  In  deep 
percussion  the  blows  are  given  with  enough  force  to  influence  the 
structures  situated  deeply  in  the  lung  or  overlapped  by  the  edges  of 
the  lung.  It  is  therefore  necessary  in  cases  of  deep-seated  consolidation, 
and  in  cases  of  aneurism  covered  by  lung,  and  in  order  to  define  its 
limits,  and  particularly  in  order  to  determine  the  true  height  of  the 
liver  and  the  relative  area  of  dulness  of  the  heart. 

Auscultatory  or  Stethoscopic  Percussion.  This  is  a  valuable 
means  of  defining  the  exact  outline  of  a  dull  area,  as  an  aneurism  or  tumor 
within  the  chest,  or  of  determining  the  limits  of  organs  even  of  similar 
physical  structure.  The  stethoscope  is  placed  over  the  organ  the  border 
of  which  is  to  be  defined,  and  percussion  is  begun  some  distance  from 
it.  It  is  conducted  toward  the  stethoscope,  and  the  dull  sound  of  the  non- 
resonant  structure  is  transmitted  to  the  ear  beyond  limits  nofdetermined 
by  ordinary  methods.  If  the  tympany  of  the  stomach  is  to  be  distin- 
guished from  the  tympany  of  the  colon^  place  the  stethoscope  over  either 
one  of  the  organs.  Percuss  with  the  finger-tips  directly  on  the  surface 
by  immediate  percussion.  Begin  at  the  stethoscope  and  percuss  from  it. 
As  soon  as  the  limit  of  the  structure  percussed  is  reached  a  difference 
of  tone  or  pitch  is  observed  which  cannot  be  detected  by  other  means. 
In  this  manner  the  dulness  of  the  liver  can  be  told  from  that  of  pul- 
monary consolidation  or  pleural  effusion  ;   the  dulness  of  an  effusion 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  257 

from  a  consolidation  of  the  lung  which  rises  higher  than  the  effusion, 
as  in  pleuro-pneumonia.      Mediate  percussion  may  also  be  employed. 

Object  of  Percussion.  The  object  of  percussion  is  to  estimate  the 
proportion  of  air  to  the  solid  tissue  contained  in  the  chest.  "VVe  can 
thus  determine  (1)  the  size  of  the  lungs;  (2)  the  presence  or  absence 
of  abnormal  physical  conditions;  (3)  the  size  of  the  other  organs  in 
the  thorax  (topographical  percussion),  and  (4)  in  the  case  of  the  abdo- 
men the  position  and  size  of  its  organs  and  the  presence  of  tumors 
or  other  solid  structures. 

The  Size  of  the  Lungs.  Increase  in  size:  The  boundaries  of  the 
lung  have  been  described.  If  the  resonance  extends  beyond  these  boun- 
daries, it  may  be  said  that  the  lungs  are  enlarged.  This  is  seen  in 
emphysema.  The  area  of  resonance  in  this  affection  extends  above  the 
clavicles  to  a  greater  height  than  in  health.  It  encroaches  upon,  and 
may  altogether  displace,  the  normal  area  of  cardiac  dulness;  it  extends 
one  and  a  half  to  two  inches  beyond  the  lower  limits  of  the  healthy  lung. 
The  upper  border  of  liver-dulness  is,  therefore,  lower — instead  of  be- 
ginning in  the  fifth  or  sixth  interspace  it  begins  an  inch  or  two  below. 
Diminution  in  size :  Shrinkage  of  the  apices  (one  or  both)  takes  place  in 
phthisis,  hence  the  resonance  of  health  does  not  extend  as  high  up  in 
the  neck.  Shrinkage  or  contraction  may  take  place  along  the  lateral 
borders  or  lower  edges  on  account  of  phthisis  or  retracting  pleurisy, 
causing  diminution  in  size  of  the  lung  and  spurious  enlargement  of  the 
heart  or  liver.  In  diseases  below  the  diaphragm,  effusion  or  enlarged 
liver,  the  size  of  the  lungs  varies.  (For  heart  and  liver,  see  the  special 
chapters  devoted  to  these  organs.) 

The  Sounds  in  Disease.  It  may  be  said  in  general  that  when 
a  sound  is  produced  in  the  thorax  which  varies  from  the  normal  reso- 
nant tone  it  indicates  an  abnormal  physical  condition,  or,  in  a  word, 
disease.  Exactly  corresponding  portions  of  the  two  sides  must  be 
compared. 

Change  in  tone  may  be  general  or  local.  The  areas  over  both  lungs 
may  yield  a  different  percussion-note  from  the  normal  (bilateral);  the 
change  may  be  limited  to  one  side  (unilateral);  or  it  may  be  found  in 
small  areas  (local). 

Increased  Resonance  or  Tracheal  Tone.  The  resonance  may  be  in- 
creased or  diminished.  When  the  resonance  is  increased  the  sound 
is  abnormally  clear.  If  it  is  fuller  and  clearer  than  in  health,  without 
the  characteristics  of  the  tympanitic  note,  it  is  known  as  hyper- 
resonance  or  exaggerated  resonance  or  a  tracheal  tone.  The  physical 
condition  which  causes  exaggerated  or  hyper-resonance  is  increase 
in  the  amount  of  air.  This  increased  amount  of  air  may  be  general, 
unilateral,  or  local.  When  general  (bilateral)  it  gives  the  character- 
istic sound  heard  in  emphysema.  In  this  affection  the  amount  of  air 
is  so  great,  and  the  tension  of  the  chest-walls  so  exaggerated,  that 
hyper-resonance  and  sometimes  a  pure  tympanitic  sound  ("  band-box  " 
resonance)  are  produced  over  the  entire  thorax.  At  the  same  lime  nor- 
mally dull  areas  are  encroached  upon.  The  heart-dulness  is  effaced, 
the  liver  dulness  lowered.  The  same  increased  resonance  may  be 
present  in  acute  miliary  tuberculosis.      Unilateral  increase  in  resonance 

17 


258 


SPECIAL  DIAGNOSIS. 


or  tympany  occurs  when  there  is  an  increased  amount  of  air  in  one 
luug,  on  account  of  compensatory  enlargement  (vicarious  or  compen- 
satory emphysema),  or  on  account  of  an  increase  of  air  in  the  pleura. 
Local  increase  of  resonance  occurs  when  a  local  area  of  the  lung  is 
acting  in  a  compensatory  manner.  This  is  seen  in  cases  of  phthisis  in 
which  the  alveoli  or  lobules  surrounding  small  areas  of  consolidations 
are  very  distended.  The  exaggerated  note  may  aid  in  the  recognition 
of  a  deep  consolidated  area.  The  same  note,  hyper-resonance,  _  or 
Skodaic  resonance,  is  obtained  over  a  portion  of  the  lung  above  the  line 
of  pleural  effusion,  and  above  the  line  of  consolidation  in  pneumonia. 


Fig.  51. 


Fig.  52. 


Diagram  showing  at  x  moderate  dulness 
ever  tubercular  infiltration.      (Gibsox  and 

RrSSELL.) 


Diagram  showing  heightening  of  pitch  an- 
teriorly at  x  from  consolidation  posteriorly 
(shaded  points).    (Gibsox  and  Russell.) 


Diminished  or  Impaired  Resonance.  The  normal  tone  or  resonance 
is  impaired  or  muffled — that  is,  the  pitch  is  higher,  while  volume  and 
duration  are  diminished — in  cases  of  incipient  consolidation  of  the  lung, 
and  in  small  pleural  effusions  in  which  the  layer  is  thin.  It  is  the  first 
change  toward  dulness,  and  is  particularly  noted  in  the  early  stages  of 
phthisis.  The  lung  area,  usually  the  apex,  is  the  seat  of  small  areas  of 
tuberculous  infiltration.  The  relative  amount  of  air  to  solid  structure 
is  lessened.  Impaired  resonance  is  the  result.  As  the  disease  advances 
the  note  changes  gradually  to  dulness. 

Pitch.  Gibson  and  Russell  have  pointed  out  the  change  in  quality 
of  sound  with  change  in  pitch.  (See  Fig.  52.)  If,  for  instance,  the 
apex  of  the  lung  is  percussed  in  front,  and  at  the  same  time  there  is 
an  effusion  of  fluid  behind,  or  a  consolidation  of  small  area  directly  on 
the  opposite  surface  of  the  lung,  the  pitch  is  higher,  compared  with 
the  sound  in  the  opposite  lung  at  the  corresponding  point,  although 
the  quality  is  clear.  A  clear  sound  of  "heightened  pitch  is  diagnostic 
of  airless  structure  behind  air-containing  structure. 

Tympany  in  Disease.  Significance  :  If  a  tympanitic  note  is  elicited 
over  a  part  where  in  health  resonance  should  be  found,  it  is  an  indica- 
tion of  disease.  It  signifies  (1)  that  air  is  confined  in  a  space  (cavity), 
or  that  there  is  an  excess  of  air  in  many  sacs,  as  in  the  lungs  in  emphy- 


DISEASES  OF  THE  LUNGS  AND  PLEURJE. 


259 


Fig 


sema  ;  (2)  that  the  tension  of  the  lungs  is  less  than  normal — the  lung- 
is  relaxed,  as  it  is  above  the  limits  of  a  pleural  effusion.  A  tympan- 
itic sound  from  the  chest  occurs — 1.  As  pre- 
viously stated,  bilaterally,  in  cases  of  emphy- 
sema. 2.  Unilaterally,  in  cases  of  pneumo- 
thorax and  compensatory  emphysema.  In 
pneumothorax  the  pitch  may  be  raised  if  there 
is  much  tension;  it  is  then  known  as  a  dull 
tympany.  3.  Locally.  It  is  limited  to  the 
lobe  of  the  lung  in  some  cases  of  compensa- 
tory emphysema.  It  may  occur  in  the  early 
stages  of  pneumonia,  or  in  the  later  stages  of 
complete  consolidation.  In  the  former  it  is 
due  to  relaxed  tension;  in  the  latter,  to  the 
air  in  the  bronchus  the  lumen  of  which  is  free. 
In  cases  of  pleural  effusion,  owing  to  altera- 
tion in  the  tension  of  the  lung,  a  tympanitic 
note  is  present  above  the  layer  of  fluid.  In 
phthisical  excavations  at  the  base  or  the  apex, 
and  in  bronchial  dilatation,  if  the  cavity  com- 
municates with  the  air,  and  has  moderately 
thin,  elastic  walls,  and  is  at  the  same  time 
empty,  a  tympanitic  note  is  produced.  The 
musical  pitch  of  the  note  depends  upon  the 
volume  of  air,  the  size  of  the  opening,  and 
tension  of  the  wall.  Large  volume  of  air, 
low  pitch;  large  opening,  low  pitch;  greater 
tension,  higher  pitch.  Small  volume,  high 
pitch;  small  opening,  high  pitch;  less  tension, 
low  pitch.  (For  modifications  of  tympany  see  Special  Sounds,  and 
Cavities.) 

Dulness  in  Disease.  The  note  is  high  in  pitch,  small  in  volume, 
and  short  in  duration.  Absence  of  air,  or  a  relatively  small  amount 
in  proportion  to  solid  structure,  is  present.  The  conditions  which  give 
rise  to  it  are  all  forms  of  consolidation  and  pleural  effusions.  The 
extent  and  the  degree  of  dulness  depend  upon  the  proportionate  amount 
of  solid  to  air-containing  material:  Moderate  dulness  is  seen  in  tuber- 
cular disease  with  moderate  infiltration  of  the  lung  (see  Fig.  51),  and 
in  small  patches  of  catarrhal  pneumonia,  in  pulmonary  congestion, 
and  in  atelectasis  and  physical  conditions  in  which  there  is  solid 
material  in  greater  proportion  than  in  health.  Absolute  dulness 
occurs  when  the  air  is  completely  absent,  as  in  the  stage  of  hepati- 
zation of  acute  pneumonia,  in  hemorrhagic  infarction,  in  condensa- 
tion from  pressure,  in  pleurisy  with  large  effusion,  or  groat  thickness 
of  the  pleura,  and  in  tumors.  Flatness  is  applied  to  the  extreme 
degree  of  dulness.     (See  Fig.  54.) 

We  have,  therefore,  all  gradations  of  the  dull  sound,  from  simple 
impaired  resonance  in  incipient  tuberculosis  of  an  apex  of  the  lung, 
as  determined  by  careful  comparison  of  the  two  apices,  to  absolute 
flatness  or  deadness.     Method  of  Percussion  :  The  kind  of  percussion 


At  the  apex  complete  dulness 
and  bronchial  breathing,  from 
tuberculous  consolidation ;  in 
the  middle  portion  impaired 
resonance,  from  disseminated 
tubercles ;  below  exaggerated 
resonance,  from  compensatory 
emphysema. 


260 


SPECIAL  DIAGNOSIS. 


necessary  to  bring-  out  the  dulness  will  depend  upon  its  extent  and 
distance  from  the  surface.  When  the  consolidation  or  thickening  is 
superficial,  possibly  lying  against  a  thickened  pleura,  light  percussion 
will  discover  it,  whereas  strong  percussion  would  bring  out  the  reso- 
nance of  the  deeper  healthy  lung-tissue  to  such  an  extent  as  to  mask 
completely  the  superficial  dulness.  On  the  other  hand,  when  the  air- 
less consolidated  tissue  is  deep-seated  and  surrounded  by  healthy  lung, 
strong  percussion  is  required  to  discover  it. 


Fig.  54. 


Retracted  lung. 


Air.  Tympany.  Metallic  tinkling 
and  amphoric  breathing. 

Succussion  on  shaking. 

Fluid.  Flat  on  percussion.  Loss  of 
vocal  resonance  and  fremitus.  Ab- 
sent breath-sounds. 


Pneumothorax  ;  resonance  over  retracted  lung.    Tympany  over  air.    Dulness  or 
flatness  over  fluid.    (Gibson  and  Russell.) 


Again,  when  the  airless  tissue  occupies  a  small  focus  and  is  sur- 
rounded by  healthy  lung,  as  in  pneumonia  beginning  centrally,  aud 
when  there  are  small  airless  foci,  as  occurs  sometimes  in  disseminated 
tuberculosis,  percussion  is  ofteu  wholly  negative. 

Special  Sounds.  Special  percussion -sounds,  or  sounds  the  quality  of 
which  differs  from  the  ordinary  tympanitic  sound,  are  present  iu  some 
physical  conditions.  Of  these  the  amphoric,  or  metallic,  and  the 
cracked-pot  percussion-sounds  are  most  familiar.  The  amphoric  sound 
is  tympanitic,  but  has  a  metallic  clang,  or  echo,  which  is  an  overtone. 
The  prolongation  of  the  sound  is  compared  to  an  echo.  It  is  like  the 
sonorousness  or  ring  of  the  voice  when  one  speaks  in  an  empty  hall. 
It  can  be  imitated  by  percussing  an  empty  vessel.  It  is  heard  best  in 
cases  of  pneumothorax  (see  Fig.  54)  and  in  phthisical  excavation  when 
the  cavity  is  large,  superficial,  with  smooth  walls,  aud  when  it  has  open 
communication  with  a  bronchus.  The  cracked-pot  sound,  as  the  name 
indicates,  resembles  that  produced  when  a  cracked  metal  vessel  is 
tapped  ;  it  is  simulated  by  clasping  the  hands  loosely  at  right-angles 
to  each  other  and  striking  them  over  the  knee.  It  is  heard  best  over 
cavities  which  communicate  directly  with  a  bronchus,  especially  if  the 
chest-wall  is  thin  and  yields  to  the  percussion-stroke.  The  cavity  is 
usually  at  the  apex.  In  order  to  elicit  the  sound  the  patient  should  be 
made  to  keep  the  mouth  open.      The  sound  should  be  created  at  the 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  261 

time  of  expiration,  and  the  percussing-  finger  should  be  retained  instead 
of  elevated  after  striking  the  pleximeter.  In  some  rare  cases  this 
sound  can  be  elicited  in  health.  It  may  be  generated  if  the  chest  of  a 
healthy  screaming  infant  is  percussed.  In  this  instance  it  is  due  to  the 
compressed  air  forcibly  throwing  the  vocal  cords  into  vibration.  The 
other  pathological  conditions  in  which  the  sound  occurs  are  pleurisy 
above  the  effusion,  pneumonia  before  consolidation  has  taken  place, 
and  pneumothorax,  if  there  is  a  free  communication  between  the  cavity 
and  a  bronchus.  In  the  latter  instance  the  sudden  rush  of  air  into  the 
bronchus  produces  this  sound.  This  is  proved  by  the  fact  that  it  can 
be  created  when  the  chest  is  percussed  in  a  case  of  empyema,  after 
the  fluid  has  been  evacuated  by  a  free  incision.  It  is  to  be  noted  that, 
while  corroborative,  it  is  not  of  itself  positive  evidence  of  any  single 
condition. 

Auscultation".  Sounds  are  produced  in  the  act  of  breathing.  They 
are  heard  by  the  application  of  the  ear  directly  to  the  chest-wall  or 
through  some  medium.  They  are  created  both  in  inspiration  and  in 
expiration.  They  vary  in  character  in  accordance  with  the  situation. 
Method.  If  possible,  the  patient  should  sit  up  in  an  easy,  unrestrained 
position.  For  auscultation  in  front,  the  arms  should  hang  carelessly 
by  the  side.  The  breathing  should  not  be  forced.  (See  page  258.) 
For  auscultation  behind,  the  patient  should  fold  the  arms  and  lean 
slightly  forward.  For  comparison  both  sides  should  have  the  same 
freedom  of  movement,  which  would  not  be  attained  if  the  patient 
assumed  a  lateral  or  side  posture  or  attitude. 

Auscultation  is  practised  by  two  methods  :  First,  a  thin  towel  or 
napkin  free  from  starch  alone  intervening,  the  ear  is  applied  directly 
to  the  chest.  This  is  known  as  the  immediate  or  direct  method.  It 
is  of  service  to  ascertain  the  general  character  of  the  sounds.  It  has 
the  disadvantage  of  imperfect  localization.  Second,  by  means  of  the 
instrument  known  as  the  stethoscope  the  mediate  or  indirect  method  is 
practised,  but  it  is  disadvantageous  in  infants  because  they  cannot  be 
kept  quiet  or  are  sensitive  to  its  pressure,  and  in  children  because 
instruments  are  alarming. 

The  advantages  of  the  stethoscope  over  direct  methods  of  ausculta- 
tion are  seen  when  it  is  necessary  to  localize  sounds.  The  definite 
localized  area  in  which  the  sound  is  produced  can  be  ascertained,  and 
sounds  in  close  proximity  differentiated.  Its  use  is  essential  in  the 
study  of  heart-sounds.  In  addition,  the  operator  is  more  lik-ly  to 
escape  from  contagious  diseases  and  vermin.  Moreover,  on  the  score 
of  delicacy,  the  stethoscope  is  preferable. 

The  stethoscopes  that  are  used  are  single  and  double,  ami  vary  in 
form  with  the  practice  of  the  operator.  It  should  be  an  absolute  rule 
with  the  student  to  become  familiar  with  and  use  one  form  of  stetho- 
scope only.  The  single  stethoscope  is  very  good  to  localize  and  deter- 
mine the  relation  of  sounds.  It  also  transmits  the  shock  of  an  aneu- 
rismal  vessel  or  of  the  heart.  The  objection  to  it  is  that  tie'  weight  of 
the  head  causes  pain  if  the  chest  is  sore,  and  the  pressure  of  the  instru- 
ment may  modify  sounds  if  bloodvessels  are  auscultated,  or  sounds  in 
close  proximity  to  the  ear,  as  a  friction.      In  the  use  of  the  single  steth- 


262  SPECIAL  DIAGNOSIS. 

oscope  the  student  should  be  particular,  first,  to  see  that  the  portion 
applied  to  the  chest  is  perpendicular  to  the  plane  of  the  area  over  which 
auscultation  is  practised.  Otherwise  slight  tilting  of  the  instrument 
will  take  place  and  outside  noises  be  transmitted  through  the  tube.  The 
operator  should  place  himself  in  an  unconstrained  position  and  see 
that  his  head  is  accommodated  to  the  position  of  the  instrument,  not 
the  latter  to  the  head.  If  the  parts  are  covered  with  hair,  an  extra- 
neous sound  from  friction  is  produced.  Oil  should  be  applied  to  obvi- 
ate this.  The  double  stethoscope  is  the  most  suitable  when  the  patient 
is  made  use  of  for  the  instruction  of  classes.  It  can  even  be  applied 
over  parts  that  are  quite  tender.  The  rule  of  application  to  the  chest 
is  the  same  as  for  the  single  stethoscope.  The  ear-pieces  should  fit 
comfortably.      The  humming  sound  in  the  tube  is  confusing  at  first. 

The  Sounds  in  Health.  Bronchial  breathing.  If  the  stetho- 
scope is  placed  over  the  trachea  at  the  top  of  the  sternum,  a  sound 
characterized  as  follows  will  be  heard  :  First,  it  attends  inspiration  and 
expiration  with  a  definite  pause  between  ;  second,  the  inspiration  and 
expiration  are  nearly  equal  in  length;  third,  they  are  of  a  tubular, 
blowing  character.  The  expiration  is  perhaps  a  little  stronger  and 
longer  than  the  inspiration.  If  the  month  is  closed,  there  is  no  change 
except  that  both  inspiration  and  expiration  are  harsher  and  sharper. 
Bronchial  breathing  is  the  term  applied  to  the  sound  which  is  heard 
in  this  situation.  It  is  one  of  the  normal  sounds  of  the  chest.  It 
may  be  heard  behind,  at  or  a  little  below  the  seventh  cervical  vertebra, 
feebler  in  quality  than  in  the  trachea,  and  in  the  interscapular-  space 
over  the  large  bronchi  as  they  leave  the  trachea.  A  sound  heard  in 
these  areas,  bronchial  in  character,  is  normal. 

Vesicular  Breathing,  or  the  Respiratory  Murmur.  If  the  ear  is 
applied  over  the  anterior  portion  of  the  chest,  or,  better  still,  in  the 
upper  axilla  or  below  the  angle  of  the  scapula  behind,  a  sound  is  heard 
both  on  inspiration  and  expiration.  It  differs  from  bronchial  breath- 
ing, however,  in  that  inspiration  and  expiration  are  changed  in  length. 
The  sound  of  inspiration  is  twice  or  three  times  as  long  as  the  sound 
of  expiration.  The  sound  of  inspiration  is  soft,  breezy,  or  sighing  in 
character,  increasing  in  intensity  to  the  end  of  full  inspiration.  It  is 
immediately  followed  by  expiration,  which  diminishes  in  intensity  as 
the  air  is  expelled,  and  terminates  when  one-half  or  two-thirds  of  the 
expiratory  act  is  completed.  The  sounds  can  be  imitated  by  breathing 
with  the  lips  in  position  required  to  pronounce  "  f  "  or  "  v." 

Cause  of  the  Sounds.  The  sound  is  caused  by  the  passage  of  air 
through  the  nares  into  the  wider  pharynx  when  the  mouth  is  closed. 
The  sounds  heard  over  the  bronchi,  the  terminal  bronchioles,  and  the 
vesicles  are  probably  created  in  the  upper  air-passages  and  transmitted 
to  the  ear  through  the  medium  of  the  bronchi.  Bronchial  breathing 
is  the  sound  unmodified,  transmitted  to  the  ear,  weakened  only  by  its 
distance  from  the  upper  air-passages.  The  vesicular  breath-sound  is 
the  same  sound  modified  on  account  of  the  intervention  of  the  air- 
vesicles  between  the  ear  and  the  larger  bronchi.  The  sound  is  thus 
smothered  or  dampened  down.  It  was  held  that  part  of  the  sound  of 
vesicular  breathing,  if  not  the  whole,  was  due  to  expansion  of  the  vesi- 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  263 

cles  and  rush  of  air  through  the  bronchioles.  The  proof,  however, 
seems  to  be  in  favor  of  the  first  view  given  chiefly  became,  when  the 
vesicular  tissue  is  removed,  as  in  pneumonia  or  other  consolidation, 
even  far  distant  from  the  trachea,  bronchial  breathing  is  produced. 

Modifications  of  the  Sound  in  Hecdth.  Exaggerated  Breath-sounds. 
Bronchial  breathing  and  vesicular  breath-sounds  are  increased  in  loud- 
ness anel  sharpness  by  strong,  rapid  breathing.  In  certain  places  a 
sound  is  heard  within  the  bounds  of  health,  which  partakes  of  the  qual- 
ities of  both  bronchial  breathing  and  the  vesicular  souni.  It  is  par- 
ticularly noticed  in  the  interscapular  region  about  the  level  of  the 
spines  of  the  scapula;,  in  individuals  in  whom,  in  this  situation,  pure 
bronchial  breathing  is  not  heard.  Its  characters  are,  first,  soft,  blow- 
ing inspiration,  or  loud,  harsh  inspiration  ;  second,  slightly  prolonged 
blowing  expiration,  more  exaggerated,  louder,  but  not  harsher,  than 
in  health.  The  term  broncho-vesicular  is  applied  to  this  kind  of  breath- 
ing. It  is  due  to  the  fact  that  the  sound  produced  in  the  upper  air- 
passages  is  conducted  to  the  ear  less  dampened  down  or  modified, 
because  the  air-vesicles  which  surround  the  bronchus  are  here  smaller 
in  number  than  are  found  in  the  remainder  of  the  lung. 

The  sounds  are  increased  in  children,  in  whom  there  are  combined 
greater  elasticity  of  the  chest- wall  and  greater  friction  throughout  the 
smaller  bronchi,  which  are  relatively  larger.  So  distinct  and  charac- 
teristic is  the  sound  in  children  that  the  term  puerile  respiration  is 
applied  to  it.  The  sounds  of  inspiration  and  expiration  are  both  inten- 
sified or  sharper  than  in  health ;  the  latter  is  relatively  prolonged. 

Feeble  Breath-sounds.  The  sounds  are  modified  by  the  condition  of 
the  chest-walls.  If  they  are  thick,  or  there  is  an  abundance  of  fat, 
the  sounds  are  fainter  or  lessened  in  intensity.  Feeble  respiratory 
power,  in  wasting  and  exhausting  diseases,  causes  feeble  breath-sounds. 
The  condition  of  the  upper  air-passages,  even  if  not  pathological,  mod- 
ifies the  sounds.  If  the  glottis  is  small,  or  there  is  a  disturbed  rela- 
tionship between  the  nose  and  pharynx,  the  sounds  will  be  modified. 
They  are  usually  weakened. 

The  Sounds  in  Disease.  Before  indicating  the  sounds  which 
arise  from  changes  in  the  physical  condition  of  the  lung,  it  may  be 
well  to  call  attention  to  the  confusion  that  always  arises  when  the 
student  is  examining  the  chest  for  the  first  time.  The  probability  is 
that  the  coincidence  of  heart-  and  lung-sounds  in  the  chest  prevents  the 
detection  of  the  respiratory  sounds.  If  attention  is  paid  to  the  rhythm, 
they  can  be  distinctly  isolated.  At  the  same  time  that  the  student  is 
auscultating  the  lungs,  the  hand  should  be  placed  on  the  thorax  or  the 
epigastrium  and  attention  fixed  upon  the  two  acts  of  respiration — 
inspiration  and  expiration.  Before  attempting  to  time  the  breathing, 
note  the  occurrence  of  each  movement,  the  expansion  of  inspiration 
and  the  contraction  of  expiration,  and  then  note  the  character  of  the 
sound  that  is  heard  in  each.  By  this  means  the  sounds  of  respiration 
are  accurately  ascertained,  anel  confusing  extraneous  sounds,  as  from 
the  heart,  distinctly  eliminated.  It  is.  well  for  the  student  to  bear  in 
mind  that  sounds  heard  in  the  chest,  which  are  departures  from  the 
normal  sounds,  always  iudicate  disease. 


264  SPECIAL  DIAGNOSIS. 

Vesicular  Breathing  Exaggerated.  Bilateral.  The  vesicular  breath- 
ing or  respiratory  murmur  is  increased,  first,  when  there  is  increase  in 
the  force  of  breathing — when  normal  respiration  is  increased  and  the 
patient  takes  full,  deep  breaths.  It  is  seen  in  some  forms  of  dyspnoea, 
as  at  the  acme  of  Cheyne- Stokes  breathing,  or  in  the  dyspnoea  of  dia- 
betic coma.  It  may  be  increased  or  exaggerated  in  certain  forms  of 
bronchitis,  particularly  when  the  small  tubes  are  narrowed  by  inflam- 
matory swelling.  Unilateral  exaggeration  or  increase  of  vesicular 
breathing  is  heard  when  the  lung  is  acting  vigorously,  or  in  a  compen- 
satory manner.  The  strong  inspiration  followed  by  strong  and  rela- 
tively prolonged  expiration  of  an  actively  moving  lung  signifies  almost 
certainly  disease  of  the  lung  of  the  opposite  side.  Local  exaggeration 
of  vesicular  breathing,  the  inspiration  harsh,  is  noted  in  cases  of 
phthisis  in  its  earliest  stages.  It  should  be  compared  with  the  sound 
of  the  opposite  side,  when  the  difference  can  easily  be  ascertained.  It  is 
heard  over  the  apex,  in  pneumonia  or  pleurisy  of  the  base,  and  vice  versa. 
Vesicular  Breathing  Diminished  or  Absent.  Anything  which  lessens 
the  amount  of  air  supplied  to  the  chest  diminishes  the  vesicular  breath- 
ing. Bilateral.  It  is,  therefore,  lessened  in  cases  of  occlusion  or 
obstruction  of  the  nares,  the  pharynx,  or  the  larynx.  It  is  lessened 
in  all  cases  in  which  the  expansion  is  interfered  with.  In  feeble  per- 
sons the  respiratory  murmur  is  particularly  weak  behind.  If  the  mus- 
cles of  respiration  are  paralyzed  or  enfeebled,  the  murmur  is  also 
lessened.  If  the  expansion  is  interfered  with  on  account  of  disease  of 
the  diaphragm,  or  pressure  upward  by  accumulations  in  the  abdomen, 
it  is  weakened.  Thickened  chest-walls  that  occur  from  disease,  as 
oedema,  weaken  the  respiratory  sound.  The  vesicular  breathing  is 
weakened  throughout  the  entire  extent  of  the  lung  in  emphysema  ; 
on  account  of  the  enfeeblement  of  respiratory  forces  and  shortening  of 
the  act  of  inspiration  less  air  enters  the  already  overfilled  chest ; 
moreover,  in  the  bronchitis  that  attends  emphysema  the  bronchioles 
are  all  more  or  less  occluded,  and  hence  the  air-supply  is  diminished. 
(See  Fig.  38.)  Unilateral  diminution  of  breath-sounds  occurs  (1)  when 
there  is  narrowing  of  the  bronchus,  as  in  cases  of  aneurism  or  medias- 
tinal tumor;  (2)  when  there  is  pleural  effusion,  which  (a)  lessens  the 
amount  of  air-space  by  compression  of  the  lung  and  (/>)  interferes  as 
a  different  conducting  medium.  (Fig-  49.)  If  pain  in  pleurisy,  pleu- 
rodynia, or  neuralgia  is  present  on  one  side,  the  breath-sounds  of  the 
affected  side  will  be  lessened.  Not  only  in  pleural  effusions  from 
serum,  blood,  pus,  or  air,  but  also  in  thickened  pleura  there  is  weakness 
or  faintness  of  the  respiratory  murmur.  It  should  not  be  forgotten 
that  effusions  and  thickenings  of  the  pleura  rarely  take  place  bilaterally; 
when  these  do  occur  the  breath-sounds  are  weakened,  but  not  to  the 
same  extent  as  when  effusion  is  limited  to  one  side.  Local  diminution 
of  breath-sounds  occurs  in  the  early  stages  of  nhthisis  or  in  the  earliest 
stages  of  pneumonia. 

It  is  well  for  the  student  to  analyze  carefully  the  sounds  during  each 
event  of  a  respiratory  act. 

Having  fixed  the  attention  on  respiration,  noted  its  divisions,  and  ex- 
cluded cardiac  rhythm,  note  (1)  the  character  of  the  sound  in  inspira- 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  265 

tion;  (2)  the  character  of  the  sound  in  expiration;  (3)  the  relative 
length  of  the  two. 

Alteration  of  the  Rhi/thm.  In  addition  to  the  character  of  the  breath- 
sounds,  we  take  cognizance  of  the  rhythm  of  the  sounds.  In  health 
the  movement  of  inspiration  and  that  of  expiration  are  almost  equal. 
but,  as  previously  noted,  the  sound  of  inspiration  is  heard  during  the 
entire  act,  while  that  of  expiration  occupies  the  first  third  or  so  of  the 
act.  The  sound  produced  during-  expiration  may  even  be  less  than  half 
the  length  of  that  produced  during  inspiration.  The  following  propor- 
tion represents  relative  lengths — Ins.  :  Exp.  :  :  3  : 1. 

Expiration  Prolonged.  The  first  notable  change  in  the  rhythm  of  res- 
piration, the  vesicular  murmur  remaining  normal,  may  be  prolongation. 
When  the  expiration  is  prolonged  it  equals  inspiration,  or  may  even 
be  longer.  This  is  due  to  difficulty  in  getting  the  air  out  of  the  chest 
— expiratory  dyspnoea,  a  physical  condition  which  enables  the  sound 
of  expiration  to  reach  the  ear.  It  is  prolonged  in  bilateral  broncho- 
vesicular  breathing  (q-v.).  Prolongation  of  expiration  all  over  the  chest 
is  seen  in  emphysema  and  asthma.  The  inspiration  is  short,  the  expira- 
tion prolonged.  Although  distinct  throughout  the  chest,  it  is  more  pro- 
nounced above  the  clavicles  and  along  the  free  margins  of  the  lung 
anteriorly.  Local  prolongation  of  the  expiration  is  of  great  diagnostic 
significance  when  areas  of  the  lung  are  partially  consolidated  and  the 
elasticity  thereby  impaired.  The  respiratory  murmur  is  harsh,  or 
puerile,  or  it  may  be  weak.  This  condition  obtains  in  tuberculosis,  and 
is  one  of  the  first  physical  signs  of  this  affection. 

Jerking  or  Interrupted  Inspiration.  Instead  of  the  smooth,  even, 
sighing,  or  breezy  inspiration  the  sound  is  created  in  puffs  or  jerks,  so 
that  during  the  act  of  inspiration,  as  the  chest  expands,  a  number  of 
successive  vesicular  sounds  are  heard  until  the  act  is  completed.  The 
physical  condition  which  causes  jerking  inspiration,  or  cog-wheel  breath- 
ing, is  found  in  the  earlier  stages  of  tuberculosis,  when  the  various 
bronchioles  are  more  or  less  occluded  by  outgrowths  of  tubercle.  The 
air  therefore  enters  different  lobules  at  different  periods  of  time,  thereby 
giving  rise  to  this  peculiar  broken  sound.  It  must  not  be  confounded 
with  the  same  character  of  breathing  that  is  heard  adjacent  to  the  heart, 
due  to  the  pressure  of  that  organ,  or  of  structures  in  intimate  relation 
therewith,  upon  portions  of  the  lung,  on  account  of  which  air  enters 
various  areas  in  puffs.  On  the  other  hand,  jerking  inspiration  some- 
times occurs  in  health.  It  is  heard  in  nervous  patients.  While  due 
to  the  physical  conditions  mentioned,  it  is  of  no  significance  unless 
attended  by  other  physical  signs. 

In  eases  of  adhesion  at  the  apex,  particularly  of  the  left  lung,  the 
same  puffing  or  jerking  inspiration  is  often  heard.  It  is  also  present 
in  aneurism,  or  disease  of  the  aorta,  pressing  upon  a  bronchus,  causing 
the  air  to  enter  the  part  in  an  intermittent  manner.  When  patholog- 
ical jerking  breathing  is  present,  the  expiration  is  prolonged,  and,  if 
the  case  is  under  observation  a  sufficiently  long  time,  bronchial  breath- 
ing will  usually  replace  the  jerky  respiratory  murmur.  Small,  moist 
rales  usually  attend  jerking  breathing  when  it  is  pathological,  especially 
if  excited  by  coughing  or  a  full  breath. 


266 


SPECIAL  DIAGNOSIS. 


Bronchial  Breathing.  The  normal  situation  of  bronchial  breathing 
in  health  has  been  indicated.  If  the  same  kind  of  breathing  is  heard 
in  any  other  portion  of  the  lung,  it  is  pathological.  It  is  generally 
indicative  of  the  presence  of  consolidation.  The  spongy  lung-tissue 
is  replaced  by  solid  conducting  material,  by  which  the  bronchial  sound 
is  conducted  to  the  ear.  It  is  heard,  therefore,  in  all  pathological 
conditions  in  which  consolidation  takes  place.  It  is  the  typical  iorm 
of  breathing  heard  in  pneumonia,  in  consolidation  of  the  lung  due  to 
tuberculosis  (see  Fig.  55),  in  hemorrhagic  infarcts,  and  in  lung  syphilis. 
It  must  not  be  forgotten,  however,  that  cases  of  pneumonia  do  exist 
without  this  type  of  breathing.  This  is  the  case  when  the  large  bronchus 
supplying  the  lungs,  or  the  bronchioles,  are  occluded  by  inflammatory 
exudate.  In  tuberculous  consolidation  it  may  be  absent  for  similar 
reasons.  In  central  pneumonia,  where  consolidation  is  deep-seated 
and  surrounded  by  lung-tissue,  bronchial  breathing  may  not  be  heard, 
or  it  may  be  postponed  until  the  third  or  fourth  day  of  the  disease,  by 
which  time  consolidation  will  have  reached  the  surface  of  the  lung. 


Fig.  55. 


Consolidated  area. 

Fremitus  increased. 

Vocal  resonance  increased. 

Dulness  on  percussion. 

Bronchial  breathing. 


Increased  vocal  resonance 
and  fremitus.     Dulness. 

Cavity  with  cavernous 
breathing  and  gurgling 
rales.    Pectoriloquy 

Hyper-resonance  on  per- 
cussion. 

Consolidation  —  bronchial 
breathing.  Increased 
fremitus  and  resonance. 
Dulness  on  percussion. 


Tubercular  infiltration. 
Impaired  resonance  on 
percussion. 

Congestion — crepitant  and 
subcrepitant  rales. 


Showing  phthisis  at  various  stages.    (Gibson  and  Russell). 


In  certain  cases  of  pleurisy  with  effusion  bronchial  breathing  exists. 
The  accumulation  is  not  great  enough  to  compress  the  lung  completely. 
The  bronchial  tubes  remain  patent,  while  the  vesicular  structure  is 
compressed.  Low-pitched  bronchial  breathing  is  heard  under  these 
circumstances.  It  is  more  pronounced  at  the  upper  layer  of  the  effu- 
sion. It  is  always  heard  close  to  the  spine  posteriorly,  where  the  lung 
is  compressed.  Sometimes  it  is  heard  above  the  limit  of  the  effusion, 
in  all  probability  because  of  relaxed  tension  of  the  lung. 

Varieties  of  Bronchial  Breathing.  All  their  characteristics  must  be 
borne  in  mind.  (See  p.  262.)  It  must  not  be  forgotten  that  bronchial 
breathing  is  not  represented  accurately  in  every  instance  by  the  sounds 
heard  over  the  trachea.  Its  character  may  be  modified  and  yet  ap- 
proach the  type  of  breathing  heard  at  that  place.      The  modification 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  267 

occurs  in  any  one  of  the  two  portions  that  go  to  make  up  the  sound  : 
(1)  The  blowing  element  niay  not  be  as  distinct  in  inspiration  as  in 
expiration;  (2)  in  rare  cases,  the  characteristic  blowing  sound  may  not 
continue  so  long  during  expiration  as  to  equal  the  inspiratory  sound. 
On  the  other  hand,  (3)  the  bronchial  breathing  may  vary  in  pitch. 
At  times  it  is  heard  in  abnormal  states  (a)  high  in  pitch,  both  in  inspi- 
ration and  expiration,  but  with  a  pure  blowing  quality  (harsh)  attend- 
ing each.  It  may  be  (6)  soft  and  low  in  pitch  attending  both  acts. 
The  strong,  high-pitched  sound  emitted  by  breathing  deeply  when  the 
lips  and  tongue  are  placed  in  position  to  pronounce  "  ch 3i  is  termed 
tubular  breathing.  It  is  the  characteristic  sound  of  croupous  pneu- 
monia. (4)  The  loudness  of  the  sound  may  also  vary.  This  depends 
largely  upon  physical  peculiarities  of  the  individual.  The  condition 
of  the  chest-walls  and  the  force  of  breathing  determine  it. 

When  pleurisy  with  effusion  coexists  with  pneumonia,  the  bronchial 
breathing,  which  should  be  audible,  is  feeble  and  distant.  Under  the 
same  circumstances  a  bleating  sound  replaces  bronchophony.  (See 
xEgophony. ) 

Mode  of  Determination.  Breathing  which  may,  during  very  quiet 
respiration,  appear  to  be  normal,  is  sometimes  discovered  to  be  bron- 
chial when  the  patient  has  a  spell  of  coughing  and  then  takes  several 
deeper  breaths  than  usual  in  rather  quick  succession.  Sometimes  the 
noise  made  in  nasal  respiration  obscures  the  pulmonary  sounds.  The 
patient  should  be  instructed  to  breathe  with  the  mouth  open,  to  take 
somewhat  deeper  breaths  than  usual,  and  to  let  expiration  follow  at 
once  upon  the  close  of  inspiration.  Many  patients  when  told  to  take 
deep  breaths  expand  their  lungs  to  the  utmost,  and  then  hold  the  air 
in  awhile,  and  allow  it  to  pass  out  slowly.  Such  a  method  usually 
defeats  the  purpose  of  the  examiner,  which  is  first  to  note  the  relative 
length  of  inspiration  and  expiration,  and  then  the  quality  of  the  two 
sounds,  first,  as  compared  with  each  other,  and,  secondly,  as  compared 
with  the  normal.  In  listening  for  bronchial  breathing  the  attention 
should  be  fixed  more  upon  the  length  and  quality  of  the  expiratory 
sound,  and  it  is,  therefore,  important  that  the  patient  breathe  so  as  to 
bring  out  its  characteristics  more  clearly;  this  he  can  do  by  taking 
several  moderately  deep  breaths  in  quick  succession  and  with  the  mouth 
open. 

Modifications  of  Bronchial  Breathing.  If  a  case  of  tuberculous  con- 
solidation is  watched,  it  will  be  found  after  a  time  that  the  bronchial 
breathing  becomes  lower  in  pitch.  It  is  heard  in  inspiration  and  ex- 
piration, but  a  more  hollow  quality  attends  the  sound.  From  the  hol- 
lowness  of  the  tone  the  word  cavernous  has  been  applied  to  the  breath- 
sound;  it  is  due  to  the  formation  of  a  cavity  in  the  consolidation,  or  to 
a  dilated  bronchus.  It  is  a  sign  of  a  cavity  (see  Fig.  55).  Cavernous 
breathing  may  have  a  metallic  quality,  and  is  then  called  amphoric.  1 1 
is  analogous  to  the  sound  produced  by  blowing  across  the  open  month 
of  a  jar.  A  large  cavity  with  smooth  walls  that  communicates  with 
the  air  is  the  cause  of  the  development  of  such  sound.  It  is  heard  also 
in  pneumothorax,  when  such  communication  exists.  The  metallic  tone 
is  analogous  to  the  metallic  percussion-sound.     It  occurs  under  the  same 


268  SPECIAL  DIAGNOSIS. 

physical  circumstances.  The  physical  condition  which  causes  it  may 
be  so  marked  that  the  same  character  of  tone  is  imparted  to  rales  pro- 
duced in  the  cavity,  or  to  the  heart-sounds  which  are  transmitted  by 
the  solidified  area  surrounding  the  excavation. 

Broncho-vesicular  Breathing  in  Disease.  The  physical  condition  is 
commencing  consolidation  surrounded  by  vesicular  structure.  It  is 
found  midway  in  the  change  from  respiratory  murmur  to  bronchial 
breathing  in  tuberculosis.  The  inspiration  is  higher  in  pitch;  the 
expiration  prolonged,  harsh,  and  blowing;  or  the  former  may  be  bron- 
chial or  tubular,  the  latter  absent.  It  may,  however,  be  indistinct 
or  masked  by  rales.  It  is  heard  sometimes  in  the  earlier  stages  of 
pneumonia,  and  is  the  modified  bronchial  breathing  which  is  heard 
when  small  areas  are  consolidated  in  capillary  bronchitis  and  catarrhal 
pneumonia,-  with  collapse  of  lobules.  The  term  "  transition  breathing  " 
has  been  applied  to  this  character  of  breath-sounds. 

New  Sounds.  The  foregoing  sounds  are  modifications  of  the  normal 
sounds  that  are  heard  during  the  act  of  breathing.  New  sounds  or 
adventitious  sounds  are  created  in  the  lungs  or  in  the  pleura.  In  the 
lungs  the  term  rales  is  applied  to  them,  and  in  the  pleura  they  are 
known  as  friction-sounds.  Under  the  same  head  may  be  classified  the 
succussion-sound  and  metallic  tinkling. 

Rales.  Rales  are  sounds  created  in  the  bronchi,  bronchioles,  and  air- 
vesicles,  or  in  pathological  excavations  (cavities).  They  are  due  (1) 
to  the  passage  of  air  through  bronchial  tubes  which  are  narrowed, 
either  on  account  of  swelling  of  the  mucous  membrane  or  on  account 
of  spasm;  or  (2)  the  passage  of  air  through  fluid  (mucus,  serum,  pus, 
blood).  The  former  are  called  "  dry  rales;"  the  latter  moist  rales,  or 
crepitation.  When  the  dry  rales  are  continuous — i.  e.,  heard  during 
both  the  acts  of  inspiration  and  expiration — they  are  known  asrhonchi. 
English  observers  divide  rales  into  two  classes — consonating  and  non- 
consonating  rales,  in  accordance  with  the  character  of  their  tone.  Con- 
sonating rales  are  metallic  or  musical  and  are  heard  over  areas  that 
yield  resonance  on  percussion.  Non-consonating  rales  are  dull  or  tone- 
less and  are  associated  with  dull  percussion-areas.  The  character  of 
the  rales  indicates  the  physical  condition  of  the  lung. 

Dry  rales  are  divided  into  (a)  sonorous  and  (6)  sibilant.  The  former 
are  large  rales,  the  character  of  which  is  indicated  by  the  name.  They 
are  created  in  the  large  bronchial  tubes.  They  are  coarse,  low-pitched 
musical  sounds.  Sibilant  rales  are  created  in  small  tubes,  and  are 
high-pitched,  whistling  sounds.  Both  are  heard  only  over  the  areas 
of  their  creation,  although  the  sonorous  rale  may  be  transmitted  all 
over  the  chest.  Both  may  be  heard  at  the  same  time.  The  dry  rales 
are  heard  in  the  early  stages  of  bronchitis,  when  the  mucous  mem- 
brane is  swollen  and  thickened,  but  has  not  begun  to  secrete  mucus  or 
muco-purulent  matter.  They  are  also  heard  in  asthma  in  which  there 
is  spasm  of  the  bronchial  tubes,  and  in  the  chronic  bronchitis  of  emphy- 
sema.    In  the  latter  the  smaller  rales  are  more  common. 

Moist  Bales,  or  Crepitation.  They  may  be  divided  into  large  or 
small  rales;  the  latter  are  also  called  subcrepitant.  (See  Fig.  55.) 
The  crepitant  rale  is  a  fine  rale,  said  to  be  created  in  the  alveoli,  due  to 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  269 

inflation  of  the  cells  whose  walls  had  been  held  together  by  exudation  or 
fluid  (oedema).  It  is  a  fine  rale  distinctly  localized,  resembling-  the  sound 
produced  by  rubbing  a  lock  of  hair  between  the  fingers  or  by  putting- 
salt  on  a  hot  plate.  In  the  early  stages  of  pneumonia  and  in  oedema 
of  the  lungs  it  is  said  to  be  pathognomonic.  It  may,  however,  be 
heard  whenever  there  are  a  small  amount  of  fluid  in  the  alveoli  and 
feeble  respiratory  action.  The  small,  moist,  or  subcrepitant  rales  are 
created  in  the  smaller  bronchioles  and  the  alveoli.  They  may  be  gen- 
eral or  local.  If  general,  they  are  due  to  bronchitis  in  the  second 
stage.  There  is  an  abundance  of  secretion  in  the  terminal  air-passages 
which  is  thrown  into  vibration  by  the  current  of  air  during  the  act  of 
breathing.  The  element  of  moisture  is  pronounced  and  gives  to  them 
their  quality,  to  which  the  term  "crackling"  is  sometimes  applied. 
They  are  found  in  congestion  with  outpouring  and  stagnation  of  secre- 
tion; in  oedema;  and  whenever  fluid  is  drawn  into  the  bronchi,  as  when 
there  has  been  a  hemorrhage  in  the  upper  passages.  Small  moist 
rales  in  local  areas  are  found  in  phthisis,  particularly  in  the  end  of  the 
first  stage,  on  account  of  the  local  bronchial  catarrh,  and  in  the  second 
stage  for  the  same  reason.  They  occur  in  the  early  stage  of  pneumonia, 
particulary  in  the  area  of  the  lung  which  is  the  seat  of  collateral  oedema 
adjacent  to  the  consolidation.  They  are  also  heard  in  the  later  stages 
of  pneumonia  when  resolution  has  taken  place.  If  this  is  reached, 
however,  they  may  be  replaced  by  large  rales.  They  may  be  heard 
around  any  consolidation  because  of  congestion,  oedema,  or  catarrh. 
It  must  not  be  forgotten  that  cough  or  forced  inspiration  must  be 
excited  before  rales  can  be  definitely  excluded. 

Large  moist  rales,  or  mucous  rales,  occur  in  the  larger  bronchial 
tubes,  or  in  cavities,  from  the  same  causes  that  produce  them  in  the 
smaller  tubes.  The  fluid,  however,  is  larger  in  amount,  the  air-current 
stronger,  and  the  space  for  vibration  is  greater.  While  sometimes 
present  in  bronchitis,  they  are  heard  in  their  most  marked  form  in  the 
third  stage  of  phthisis.  They  are  described  as  bubbling  and  gurgling 
rades,  and  are  very  characteristic  after  a  full  breath  or  a  cough.  (See 
Fig.  55.) 

Rales  are  to  be  distinguished  from  other  adventitious  sounds. 
Although  in  some  instances,  as  when  rales  are  heard  over  the  bases 
of  the  lungs,  it  is  almost  impossible  to  distinguish  them  from  friction 
sounds,  they  have  nevertheless  certain  marked  characteristics.  We 
recognize  rales,  first  by  the  qualities  previously  mentioned.  Second, 
by  their  location;  if  the  adventitious  sounds  are  general,  they  arc  due 
to  rales.  Third,  rales  are  modified  by  cough  or  breathing.  They  may 
be  intensified  by  cither  act,  or,  after  the  completion  of  the  act,  may 
disappear  entirely.  On  quiet  breathing,  in  the  early  stages  of  tuber- 
culosis, for  instance,  they  may  not  be  heard  at  all.  It  is  absolutely 
necessary,  before  excluding  them,  to  have  the  patient  cough  ami  then 
take  a  full  breath.  Fourth,  they  vary  in  position.  This  may  occur 
from  hour  to  hour.  If  the  chest  is  examined  in  the  morning,  they  may 
be  more  pronounced,  for  instance,  at  the  base.  At  another  time  in 
the  twenty-four  hours  they  arc  distinct  at  the  apex.  They  arc  more 
likely  to  be  present  at  the  base  if  the  patient  is  kept  in  the  recumbent 


270  SPECIAL  DIAGNOSIS. 

posture.  Fifth,  they  vary  in  character.  At  one  time  small,  moist 
rales  are  heard;  in  a  short  time  they  are  replaced  by  larger  rales. 
Dry  rales  are  regularly  followed  by  moist  rales  in  the  course  of  bron- 
chitis. In  a  case  of  bronchial  asthma  all  sorts  of  rales  may  be  heard 
in  a  few  hours.  Sixth,  they  seem  to  be  further  away  from  the  listen- 
ing ear  than  are  friction-sounds. 

Kales  in  the  bronchi  must  not  be  confounded  with  the  crepitant  or 
fine  crackling  sound  which  is  heard  at  the  base  of  the  lung  in  patients 
who  have  been  ill  with  the  exhaustive  fevers  and  who  have  not  taken 
full  breaths  for  some  time.  They  disappear  after  the  patient  has 
inspired  deeply  half  a  dozen  times. 

Rales  throughout  the  lung  are  not,  in  themselves,  diagnostic  of  any 
affection  save  bronchitis,  in  winch,  with  the  absence  of  other  physical 
signs,  their  occurrence  all  over  the  chest  is  significant.  In  the  absence 
of  this  affection  rales  at  the  base  of  both  lungs  are  due  to  congestion. 
Rales  at  one  apex,  with  failing  health,  point  to  the  onset  of  tuberculosis. 

Friction-sound.  In  health  the  two  surfaces  of  the  pleura  rub 
together  without  making  any  sound.  If  they  are  inflamed,  the  sur- 
faces are  roughened,  as  swelling  and  dilatation  of  the  capillaries  pro- 
duce a  more  or  less  granular  surface,  or  because  of  transudation  of 
fluid  or  lymph.  Under  these  circumstances  rubbing  together  of  the 
two  surfaces  creates  a  sound  to  which  the  term  friction  is  applied.  It 
is  heard  at  the  end  of  inspiration,  and  may  continue  during  expiration. 
It  is  a  localized  sound,  usually  at  the  seat  of  pain;  it  is  near  to  the 
ear,  and  is  not  modified  by  cough  or  full  breathing,  except  occasionally 
by  the  latter  when  repeated.  It  occurs  in  "nests"  or  "  bunches." 
It  may  be  increased  by  the  pressure  of  the  stethoscope.  Moreover,  it 
is  a  fixed  sound,  in  that  it  does  not  disappear  until  effusion  takes  place. 
It  may  reappear  again  when  the  fluid  subsides.  The  above  character- 
istics distinguish  it  from  rales.  Both,  however,  may  occur  together. 
Although  almost  always  of  respiratory  rhythm,  when  the  pleurisy  is 
in  the  neighborhood  of  the  heart,  the  friction  may  be  of  cardiac 
rhythm.  Under  these  circumstances  it  is  more  distinct  during  the  act 
of  inspiration.  It  is  heard  as  a  systolic  rubbing,  often  of  respiratory 
rhvthrn,  along  the  borders  of  the  heart. 

We  not  only  distinguish  the  friction-sound  by  the  characters  just 
indicated,  but  also  by  the  presence  of  pain,  which  renders  its  existence 
more  probable.  Usually  it  is  heard  at  the  base,  in  the  nipple-line  in 
front,  or  at  the  angle  of  the  scapula  behind,  and  frequently  in  the 
axillary  region. 

In  addition  to  the  friction-sound  that  attends  the  onset  of  acute 
inflammation,  creaking  sounds  of  the  same  nature,  not  unlike  the 
sounds  produced  when  an  old  door  is  swung  on  rusty  hinges,  or  when 
new  leather  is  bent,  are  heard  in  cases  of  old  pleurisy.  Other  physical 
signs  of  pleural  adhesions  are  present,  and  a  friction-fremitus  is  often 
transmitted  to  the  hand.  An  old  friction  is  often  heard  at  the  apex, 
in  the  neighborhood  of  old  cavities.  It  attends  both  inspiration  and 
expiration,  is  not  modified  by  cough,  nor  has  it  any  of  the  elements  of 
the  moisture  that  attends  moist  rales.  The  patient  may  be  cognizant  of 
the  grating;  or  rubbing  sensation,  and  be  able  to  describe  the  sensation 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  271 

during  each  breath.  It  may  continue  a  long  time  after  an  acute  pleural 
effusion  has  disappeared,  and  is  sometimes  the  source  of  anxiety  upon 
the  part  of  the  patient. 

Pyaemic  deposits  in  the  lungs,  infarction,  bronchiectasis  with  reactive 
pneumonia,  and  pleurisy  with  emphysema,  are  first  revealed  by  pleu- 
ritic frictions.  (Vierordt.)  At  the  base  of  the  right  lung  they  may  be 
the  first  indication,  or  at  least  an  early  one,  of  hepatic  abscess.  (Clark.) 
The  pleural  friction  in  the  hepatic  region  must  not  be  confounded  with 
peritoneal  friction  of  respiratory  rhythm.  In  a  case  of  secondary 
cancer  of  the  liver  a  friction-sound  was  heard  in  the  seventh  interspace 
from  perihepatitis  over  a  cancerous  nodule. 

Metallic  Tinkling.  The  impression  imparted  to  the  listener  is  that 
of  the  falling  of  some  material  into  fluid  in  a  hollow  space.  The  phy- 
sical condition  is  that  of  a  cavity  partly  filled  with  fluid,  partly  filled 
with  air,  into  which  there  is  dropping  from  an  opening  above.  It  is 
seen  in  hydro-  or  pyo-pneumothorax  and  in  a  few  cases  of  large 
cavities.  The  air-chamber  acts  as  a  consonance-box  and  resonator, 
aud  gives  a  metallic  quality  to  the  sound.  Other  physical  signs  of 
cavity  and  fluid  are  associated.  It  may  be  heard  when  the  patient  is 
breathing  quietly,  or  only  after  coughing.  Sometimes  only  tinkling 
is  heard,  or  the  sound  of  a  number  of  drops  is  transmitted.  The  latter 
occurs  after  coughing. 

Bell-tympany.  The  bell-sound  is  heard  when  air  is  confined  in  the 
pleura.  If  the  stethoscope  is  placed  over  the  pleural  cavity,  and  two 
coins  are  used  as  plessor  and  pleximeter,  a  distinct  metallic  or  anvil- 
sound  is  transmitted  to  the  ear.  The  cavity  containing  air  can  be 
clearly  outlined  if  the  metal  pleximeter  is  moved  about.  As  soon  as 
it  passes  over  a  part  of  the  chest  under  which  no  air  is  confined  the 
sound  is  not  heard.  Although  heard  in  nearly  all  cases  of  pneumo- 
thorax, there  are  some  cases  in  which  it  cannot  be  elicited,  probably 
because  of  the  small  size  of  the  aperture  in  the  pleura. 

Succussion.  The  ear  is  placed  to  the  side  of  the  chest,  and  the 
patient's  body  moved  suddenly  by  himself  or  by  the  observer.  A 
splashing  sound  is  heard.  It  can  only  be  produced  when  there  is  air 
as  well  as  fluid  present  in  a  cavity.  It  was  first  described  by  Hippoc- 
rates, and  the  term  "  Hippocratic  succussion"  has  been  given  to  it. 
It  is  characteristic;  of  hydro-pneumothorax,  although  not  present  in 
all  cases  of  this  disease.  The  sound  may  be  audible  at  a  distance. 
Metallic  tinkling  can  usually  be  heard  at  the  same  time. 

Auscultation  of  the  Voice.  When  the  ear  or  stethoscope  is 
applied  to  the  surface  of  the  chest  and  the  patient  is  asked  to  speak,  the 
vibrations  of  the  air  in  the  trachea  and  bronchial  tubes  are  transmitted 
to  the  chest- wall  and  become  audible.  The  sound  is  known  as  the  vocal 
resonance.  It  is  a  sign  which  goes  hand-in-hand  with  rocal  or  tactile 
fremitus,  and  is  modified  by  the  same  conditions  which  modify  the 
latter.  In  disease  it  may  be  increased  or  diminished.  While,  in  gen- 
eral, conditions  which  increase  the  fremitus  increase  the  vocal  reso- 
nance also,  this  is  not  invariably  the  case.  Sometimes  one  is  increased 
and  not  the  other,  without  there  being'  any  evident  reason  for  it.  It 
varies  in  health  under  similar  circumstances.      The  sound  is  purring  or 


272  SPECIAL  DIAGNOSIS. 

buzzing.  It  is  heard  more  pronounced  at  the  right  apex  than  at  the 
left;  in  persons  with  thin  chest- walls;  in  individuals  in  whom  the  voice 
is  low  in  pitch  and  strong.  It  is  lessened,  therefore,  in  females  and 
children.  It  diminishes  the  further  away  the  ear  gets  from  the  larynx, 
and  hence  is  feebler  at  the  bases.  It  is  immaterial  what  words  are 
selected  by  the  patient  to  create  the  resonance.  It  is  important  for 
the  student,  however,  to  become  familiar  with  the  resonance  of  a 
definite  series  of  words  which  when  pronounced  do  not  need  any 
marked  change  in  inflection  of  the  voice.  The  words  "  one,"  "  two," 
"  three,"  or  "  ninety-nine,"  spoken  repeatedly,  are  selected.  The 
patient  should  not  raise  or  lower  his  voice  during  the  act  of  speaking. 
Symmetrical  portions  of  the  two  sides  of  the  chest  must  be  examined 
successively. 

Vocal  Resonance  Increased.  Increased  vocal  resonance  depends  upon 
the  intensity  or  extent  of  the  cause.  When  slightly  above  normal  it 
is  referred  to  as  slight  increase,  or  when  the  voice  is  transmitted  com- 
paratively distinctly  to  the  ear  it  is  known  as  bronchophony.  This 
may  be  heard  in  health  over  the  trachea,  or  over  the  bronchi  behind. 
When  heard  over  the  vesicular  structures  of  the  lung,  it  indicates  that 
the  vibrations  are  transmitted  to  the  ear  by  some  better  conducting 
material.  This  is  usually  a  consolidated  lung,  and  hence  :  1.  In  all 
cases  of  consolidation  the  resonance  is  increased,  that  is,  bronchophony 
is  created;  but  in  pneumonia,  if  the  bronchus  is  occluded  by  exudate, 
it  is  absent.  2.  If  the  lung  is  collapsed  but  the  bronchi  open,  the  reso- 
nance is  increased.  3.  It  is  also  increased  in  cavities.  Sometimes 
the  resonance  is  intensified  and  the  sound  is  even  more  pronounced 
than  when  heard  over  the  trachea. 

Pectoriloquy.  The  voice  may  be  so  distinctly  transmitted  that  we 
have  the  impression  that  the  patient  is  speaking  into  the  mouth  of  the 
stethoscope.  If  the  patient  speaks  slowly  the  words  may  be  distinctly 
heard.  It  is  more  striking  when  the  patient  whispers.  The  term 
"  whispering  pectoriloquy  "  is  then  applied  to  it.  It  is  detected  over 
a  cavity  if  it  communicates  with  a  large  bronchus,  and  iu  consolidation 
of  the  lung. 

Vocal  Resonance  Diminished.  Vocal  resonance  is  diminished  or 
absent  when  anything  cuts  off  the  supply  of  air,  and  intercepts  the 
vibrations  from  the  part  over  which  the  observer  is  auscultating.  Fre- 
mitus and  resonance  are  absent  over  the  area  supplied  by  a  bronchus 
which  is  occluded  by  external  pressure,  as  an  aneurism.  Diminution 
or  absence  of  vocal  resonance  is  more  marked  in  cases  of  pleural  effu- 
sion (serum,  blood,  pus,  or  air)  or  thickened  pleura.  The  vibrations 
are  impeded  because  of  the  difference  of  conducting  materials  The 
degree  of  diminution  depends  upon  the  amount  of  effusion. 

Modifications  of  Vocal  Resonance.  1.  At  the  uppermost  limit  of 
the  pleural  effusions,  at  which  point  the  layer  of  fluid  is  thin,  the 
resonance  is  transmitted  in  a  modified  form.  It  is  tremulous  and 
bleating  in  character,  and  is  known  as  ozgophony  because  it  resembles 
the  bleat  of  a  goat.  It  is  especially  heard  at  the  angle  of  the  scapula, 
or  below  it  in  cases  of  moderate  effusion.  It  is  due  to  the  fact  that 
the  fundamental  tones  are  intercepted  by  the  fluid,  while  the  other 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  273 

tones  are  allowed  to  pass  through  and  give  the  peculiar  bleating  sound. 
(Gee.)  2.  The  vocal  resonance  may  have  a  metallic  character  in  cases 
of  pneumothorax  when  there  is  free  communication  with  the  bronchus. 

Cavities.  Pulmonary  cavities  are  due  to  destruction  of  lung  by 
abscess,  gangrene,  or  tuberculosis,  or  to  dilatation  of  the  bronchi. 

As  there  is  usually  a  local  increase  in  the  amount  of  air  in  cavities, 
there  is  in  consequence  a  local  area  of  exaggerated  resonance,  or  tym- 
pany, and  with  it  the  occurrence  of  cavernous  breathing,  or  breathing 
of  an  amphoric  type.  The  presence  of  a  cavity,  however,  is  often 
difficult  to  recognize,  because  of  the  relation  to  the  surrounding  struc- 
ture or  because  of  fluid  contents.  If  the  lung  about  it  is  the  seat  of 
consolidation,  the  physical  signs  of  this  consolidation  may  override  the 
signs  of  a  cavity.  If  compensatory  emphysema  surround  the  cavity, 
it  may  be  almost  impossible  to  recognize  it.  Moreover,  the  contents 
of  the  cavity  render  the  recognition  of  its  presence  difficult.  If  it 
contains  a  large  amount  of  fluid,  the  signs  of  consolidation  alone  may 
be  present.  Much  attention  has  been  paid  to  the  recognition  of  cavi- 
ties, and  some  methods  have  been  proposed  by  which  it  is  thought  they 
can  be  distinguished.  While  it  is  a  satisfaction  to  determine  exactly 
the  presence  aud  location  of  a  cavity,  it  is  not  an  essential  to  diagnosis. 
To  confirm  the  presence  of  an  excavation,  even  if  the  physical  signs 
point  to  its  occurrence,  the  diagnosis  should  be  controlled  by  examina- 
tion of  the  sputum.  If,  on  such  examination,  yellow  elastic  tissue  is 
found,  the  presence  of  a  cavity  is  more  probable.  The  methods  em- 
ployed to  determine  the  presence  of  cavities  absolutely  have  been  named 
after  the  observers  who  devised  them. 

First,  Wintrich's  change  of  sound.  If  the  cavity  communicates  with 
a  large  column  of  air  in  the  bronchus,  and  percussion  is  employed  with 
a  moderate  degree  of  force,  the  note  will  change  as  the  patieut  alter- 
nately opens  and  closes  the  mouth.  If  the  mouth  is  open  wide,  the 
souud  is  louder  and  more  distinctly  tympanitic  and  higher  in  pitch. 
If  the  mouth  is  closed,  the  sound  is  correspondingly  lessened  and  not 
so  tympanitic.  Indeed,  sometimes  a  sound  is  obtained  with  scarcely 
a  trace  of  tympany.  This  change  of  sound  is  in  all  probability  due 
to  change  in  the  resonant  cavities  in  the  upper  respiratory  tract.  It 
must  not  be  confounded  with  "  Williams's  tracheal  tone,"  which  can 
be  elicited  near  the  junction  of  the  clavicle  and  sternum  on  the  left 
side,  in  cases  of  consolidation  of  the  underlying  portion  of  the  lung, 
particularly  if  the  force  of  the  blow  is  directed  toward  the  trachea. 
Strong  percussion  is  necessary  to  bring  out  Williams's  tone. 

Second,  interrupted  change  of  sound,  also  described  by  Wintrich,  is 
distinguished  from  the  simple  change,  in  that  it  occurs  in  different 
positions  of  the  body.  It  may  be  heard  when  the  patient  is  in  an 
upright  position,  and  disappear  when  he  assumes  the  recumbent  posi- 
tion; or  the  couverse  may  be  true.  The  change  in  position  changes 
the  relation  of  the  bronchus  to  the  cavity,  on  account  of  which  the 
varying  tympanitic  souud  is  produced. 

Third,  GerhardVs  change  of  sound.  This  change  depends  upon  the 
alteration  of  the  level  of  the  fluid  when  the  patient  assumes  the  up- 
right, or  the  dorsal  position.     It  is  not  necessary  that  the  cavity  com- 

18 


274  SPECIAL  DIAGNOSIS. 

municate  with  the  large  bronchus.  It  is  a  certain  symptom  of  a  cavity, 
but  is  rare.  The  souud  changes  in  pitch  and  in  the  degree  of  tympany. 
It  may  be  absolutely  dull  over  the  lower  part  of  the  cavity  when  the 
upright  position  is  assumed,  because  the  fluids  gravitate  to  this  portion 
and  come  in  contact  with  the  chest-wall. 

Fourth,  Friedreich's  respiratory  change  of  sound.  The  pitch  of  the 
souud  becomes  higher  at  the  end  of  a  deep  inspiration.  It  depends 
upon  increased  tension  of  the  chest-wall  and  lung-tissue,  as  well  as  of 
the  wall  of  the  cavity  during  the  act  of  inspiration.  It  may  be  a 
source  of  confusion,  which  is  obviated  by  percussing  at  the  same  stage 
of  the  breathing  each  time,  or  percussing  only  on  superficial  breathing. 

Fifth,  Seitz  has  called  atteution  to  a  form  of  breathing  named  meta- 
morphosing. Inspiration  begins  harshly  bronchial,  then  becomes  faintly 
bronchial,  the  latter  sound  being  heard  also  in  expiration.  It  is  said 
to  be  a  sure  sign  of  cavity. 

Resume.  The  student  must  bear  in  mind  when  listening  to  the 
respiratory  sounds  to  note  :  (1)  If  the  sounds  are  increased  or  dimin- 
ished in  intensity;  (2)  the  rhythm  of  the  inspiratory  and  expiratory 
sounds;  (3)  if  the  respiratory  murmur  is  replaced  by  bronchial  breath- 
ing or  its  modification;  (4)  the  presence  of  new  sounds  (rales  and  fric- 
tion); (5)  to  auscultate  in  order  to  determine  the  voice-sounds. 

Mensuration.  By  mensuration  or  thoracometry,  the  results  "se- 
cured by  palpation  are  confirmed  and  more  accurately  attained.  The 
size  of  the  chest  and  its  degree  of  expansion  are  ascertained.  Hence 
the  circumference  and  diameter  of  the  chest  are  ascertained  and  the 
differences  in  the  shape  and  movement  of  two  sides  made  manifest. 
If  the  measurement  is  taken  from  day  to  day,  it  can  be  graphically 
recorded  by  tracing  sections  on  paper,  and  delicate  changes  can  thus 
be  definitely  ascertained.  The  circumference  of  the  chest  is  measured 
by  means  of  the  ordinary  tape-measure  or  by  metal  tapes  joined 
together  by  a  hinge.  The  latter  can  be  made  to  fit  accurately  the 
circumference  of  the  chest,  and  are  essential  in  order  to  transfer  the 
section  to  paper.  The  middle  of  the  hinge  is  held  firmly  over  the 
spinous  process  of  the  vertebra,  while  the  two  limbs  are  carried  around 
the  chest,  moulded  to  all  inecpialities,  and  crossed  in  front,  one  above 
the  other;  a  mark  is  made  on  each  where  it  crosses  the  middle  line. 
Measurements  should  be  taken  at  about  the  level  of  the  nipples,  and 
two  inches  below  them,  and  care  should  be  taken  to  have  the  level  the 
same  in  front  and  behind.  They  should  be  taken  in  full  inspiration 
and  expiration,  and  in  repose.  The  outline  secured  by  this  method 
need  not  be  disturbed,  as  by  flexion  on  the  hinges  we  are  enabled  to 
remove  it  intact.  The  tapes  are  carefully  transferred  to  a  sheet  of 
paper  on  which  imaginary  diameters  have  been  marked.  After  fixing 
the  corresponding  points  of  the  tapes  on  the  lines  of  the  respective 
diameters,  the  outline  can  then  be  traced. 

Woillez's  cyrtometer  is  a  chain  with  links  which  is  used  to  ascertain 
the  exact  circumference.  The  diameter  of  the  thorax  is  secured  by 
means  of  caliper  compasses.  The  antero-posterior  diameter  should  be 
taken  on  a  level  with  the  nipple  and  the  insertion  of  the  second  rib 
behind;  the  transverse  diameter  at  the  highest  points  of  the  axilla?. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  275 

The  length  of  the  chest  may  be  ascertained  by  measuring  in  the  mid- 
clavicular line  from  the  clavicle  to  the  border  of  the  ribs.  It  is  im- 
portant to  remember  that  the  right  side  of  the  chest  measures  a  little 
more  than  the  left  in  people  who  are  right-handed. 

The  respiratory  capacity  is  estimated  by  measurement  of  the  circum- 
ference of  the  chest.  This  is  secured  by  taking  the  measurement  at 
the  end  of  complete  expiration  and  then  at  the  end  of  complete  inspi- 
ration. In  health  the  difference  between  the  two  should  be  from  five 
to  ten  centimetres  (two  to  four  inches).  If  the  expansion  is  less  than 
two  inches,  it  is  considered  deficient  by  insurance  companies,  and  the 
risk  is  not  regarded  as  first-class.  The  expansion  is  less  in  women. 
In  taking  the  measurement  the  observer  must  be  particular  to  keep 
the  terminal  portion  of  a  tape-measure  fixed  in  the  median  line  of  the 
structure.  The  other  portion  is  to  be  held  in  the  hand,  so  as  to  move 
with  inspiration  and  expiration.  Always  mark  in  advance  the  anterior 
mesial  line  and  note  the  exact  level  at  which  measurements  are  made 
when  they  are  taken  daily.  Deficiency  of  chest-expansion  not  only 
indicates  the  presence  of  a  local  morbid  process  —  notably  incipient 
tuberculosis,  but  it  also  indicates  lack  of  strength  and  of  muscular 
development,  of  physiological  deficiencies,  rather  than  physical,  and  is 
an  unerring  guide  to  the  need  of  respiratory  gymnastics. 

Spirometry.  By  means  of  the  spirometer  Dr.  John  Hutchinson 
has  been  able  to  estimate  the  quantity  of  air  taken  in  with  each  inspi- 
ration and  discharged  with  expiration.  By  it  the  respiratory  or  vital 
capacity  is  estimated.  The  data  ascertained  are  not  of  much  diagnostic 
significance,  although  if  measurements  are  made  from  day  to  day  we 
may  be  able  to  estimate  the  extent  of  recovery  from  disease  of  the 
lung  which  was  incapacitated.  When,  however,  there  is  an  important 
diminution  of  lung-capacity,  tuberculosis  may  be  suspected,  before  sub- 
jective and  objective  signs  warrant  a  diagnosis.  We  can  also  estimate 
the  degree  of  interference  with  breathing  by  disease  below  the  dia- 
phragm. Spirometry  is  of  particular  value  because  it  shows  in  a 
graphic  manner  the  need  for  respiratory  gymnastics.  By  means  of 
Waldenburg's  pneumotometer  the  respiratory  pressure  of  air  on  inspi- 
ration and  expiration  is  determined.  Expiratory  pressure  is  dimin- 
ished in  emphysema,  and  the  degree  of  diminution  may  furnish  a  clue 
to  the  severity  of  the  disease  or  the  degree  of  improvement.  It  is  to 
be  remembered  that  the  expiratory  pressure  always  exceeds  the  inspi- 
ratory pressure  in  health  by  as  much  as  20  to  30  millimetres,  according 
to  Waldenberg.  It  is  natural  to  find  that  inspiratory  pressure  is  less- 
ened in  stenosis  of  the  air-passages,  in  phthisis  and  in  pleural  effusions, 
although  it  is  not  of  diagnostic  significance.1 

1  Measurements  of  the  Chest  and  Lung  Capacity. 

(Otis,  Boston  Medical  and  Surgical  Journal,  1895.) 
Table  I. — Chest  Measurements. 

Repose,      Inflated,    Difference, 
Girth,  muscular.— Men :  inches.       indies.         inches. 

Average  of  Dr.  E.  O.  Otis,  1000  measurements,  between 

sixteen  and  forty  years  of  age  .       .        .     ■   .        .        .    34.0  36.1  2.] 

Average  of  Dr.    Hitchcock,  of  Amherst  College,  8000 

measurements .    34.6  86.5  L.9 

Average  of  E.  Hitchcock,  Jr.,  of  Cornell  College,  15,000 
measurements 84.5  36.3  L.8 


276 


SPECIAL  DIAGNOSIS. 


Powel  lays  great  stress  upon  the  faet  that  in  phthisis  the  inspiratory 
capacity  is  diminished,  but  the  expiratory  power  remains  normal. 

Combination  of  Physical  Signs.  In  order  to  determine  the 
physical  condition  of  the  lung  it  is  necessary  to  draw  conclusions  from 
the  results  obtained  by  all  the  methods  of  physical  examination.  It  is 
the  exception  that  any  one  sign  is  pathognomonic  of  a  physical  condi- 
tion. If  the  student  will  glance  over  the  abnormal  physical  conditions 
which  may  take  place  in  the  lung,  he  will  find  that  they  may  be  divided, 
first,  into  physical  changes  in  the  lung  proper,  and,  second,  into  phys- 
ical changes  in  the  pleura.     With  regard  to  the  lung,  it  will  be  further 


Repose, 
inches. 


Girth,  muscular. — Women  : 

Mt.  Holyoke  and   Wellesley  students.     Measurements 
of  Miss  Wood  and  Dr.  Mary  Col  ton  .....    29.5 

Chest,  respiratory. — Men  : 

Average  of  Dr.  E.  O.  Otis,  1000  measurements  .        .        .    31.1 
Chest,  respiratory. — Women : 

50  per  cent,  of  1500  Wellesley  students,  Miss  Wood  .       .    24.6 
Depth  of  chest.— Men  : 

Average  of  Dr.  E.  O.  Otis,  1250  measurements  in  repose 
and  362  inflated 7.5 

Depth  of  chest.— Women  ; 

50  per  cent,  of  1500  students  at  Wellesley,  Miss  Wood     .      6.9 
Breadth  of  chest. — Men  : 

Average  of  Dr.  E.  O.  Otis,  400  measurements    .       .        .9.9 


Inflated, 
inches. 

31.5 


27.2 


8.3 


10.8 


Difference, 
inches. 

3.0 


2.6 


0.8 


0.9 


Table  II. — Capacity  of  Lungs. 
Men :  Cubic  inches. 

Average  of  Dr.  E.  O.  Otis,  1000  measurements 240.6 

Hitchcock,  8000  measurements 230.0 

Hitchcock,  Jr.,  15,000  measurements 236.6 

Women ; 

Mt.  Holyoke  and  Wellesley  students,  measurements  of  Miss  Wood  and  Dr. 

Mary  Colton 145.8 

50  per  cent,  of  1500  Wellesley  students,  Miss  Wood 150.3 


Table  III. — Comparison  of  the  "vital"  or  lung  capacity  and  the  amount  ot 
air  expelled  after  an  ordinary  quiet  inspiration. 

Average  of  Dr.  E.  O.  Otis,  150  measurements. 


Vital  capacity,  or  the  amount  of  air  exhaled  after  a  full  inspiration  . 
Amount  of  air  exhaled  after  an  ordinary  quiet  respiration 
Difference,  or  "  complemental "  or  "reserve"  air 


Cubic  inches. 

230.5 

129.3 

101.2 


Difference  as  given  by  Hermann 97.6 

Average  Lung-capacity  for  Height  (Otis). 


Height. 

66  to  67  inches,  inclusive. 

167.7  to  170.3  centimetres. 

67  to  68  inches,  inclusive. 

170.3  to  172.8  centimetres. 

68  to  69  inches,  inclusive. 

172.8  to  175.4  centimetres. 

69  to  70  inches,  inclusive. 

175.4  to  177.9  centimetres. 

70  to  71  inches,  inclusive. 

177.9  to  180.5  centimetres. 

71  to  72  inches,  inclusive. 

180.5  to  183.0  centimetres. 

General  average 


Lung-capacity. 

231.62  cubic  inches. 
3797  cubic  centimetres. 

237.10  cubic  inches. 
3903  cubic  centimetres. 

244.44  cubic  inches. 
4007  cubic  centimetres. 

259.34  cubic  inches.  . 
4250  cubic  centimetres. 

261.38  cubic  inches. 
4284  cubic  centimetres. 

261.34  cubic  inches. 
4284  cubic  centimetres. 


Average  for  each  inch  or 
centimetre  in  height. 
3.4-f  cubic  inches. 
22.4   cubic  centimetres. 

3.46  cubic  inches. 
22.7    cubic  centimetres. 

3.5    cubic  inches. 
23.06  cubic  centimetres. 

3.66  cubic  inches. 
24.06  cubic  centimetres. 

3.64  cubic  inches. 
23.9    cubic  centimetres. 

3.5    cubic  inches. 
23.03  cubic  centimetres. 


'  3.52  cubic  inches,  for  each  inch  of  height. 

.23.19  cubic  centimetres,  for  each  centimetre  of  height. 


DISEASES  OF  THE  LUNGS  AND  PLEUIUE.  277 

noted  that  the  changes  are  due  to  an  increased  amount  of  air  or  to  a 
diminution  in  the  amount  of  air. 

Increase  in  the  amount  of  air  may  be  general,  unilateral,  or  local, 
and  is  indicated  by  a  combination  of  physical  signs  which  are  usually 
unerring.  On  inspection  (a)  enlargement,  general,  unilateral,  or  local; 
(6)  increased  action  in  general  emphysema,  although  with  diminished 
respiratory  excursion;  when  unilateral  or  local,  increased  action  and 
increased  expansion  (compensatory  emphysema).  On  palpation,  inspec- 
tion confirmed,  and  vocal  fremitus  diminished  when  the  increased 
amount  of  air  is  general,  slightly  increased  when  it  is  unilateral  or 
local.  On  percussion  in  each  instance  exaggerated  resonance  or  tym- 
pany. On  auscultation,  when  general  (emphysema),  feeble  respiratory 
murmur,  with  prolonged  expiration;  when  unilateral  or  local,  exagger- 
ated respiratory  murmur.  The  difference  in  the  physical  signs  of 
increased  amount  of  air  is  not  due  to  the  difference  in  quantity,  but 
to  the  associate  physical  condition  and  the  force  of  the  movement  of 
the  air.  The  diminished  expansion  and  feeble  respiratory  murmur  in 
emphysema  are  due  to  inability  to  exhale  the  air  because  of  the  dimin- 
ished elasticity  of  the  lung,  while  the  bronchioles  occluded  from  bron- 
chitis lessen  the  fremitus.  In  cavities — local  increase  of  air — the 
physical  condition  of  the  tissue  which  surrounds  them  modifies  the 
physical  signs. 

Decrease  in  the  Amount  of  Air.  The  diminution  in  the  amount  of 
air  from  change  in  the  physical  condition  of  the  lung  is  due  to  consol- 
idation or  to  collapse.  The  latter  occurs  when  the  bronchus  is  ob- 
structed, the  former  in  congestion,  pneumonia,  gangrene,  abscess, 
forms  of  tuberculosis,  and  hemorrhagic  infarct.  The  physical  signs 
are  the  same  under  all  circumstances,  except  in  collapse  :  expansion 
lessened,  fremitus  increased,  dulness,  bronchial  breathing.  The  sigus 
vary  with  the  degree  of  consolidation  as  follows  :  Slight  increase  to 
greatly  increased  fremitus,  impaired  resonance  to  complete  dulness, 
broncho-vesicular  to  bronchial  breathing.  In  tuberculosis  there  may 
be  flattening  of  chest-wall,  but  otherwise  the  signs  are  the  same.  ( 
The  presence  of  new  sounds  depends  upon  the  amount  of  secretion  or 
fluid,  as  is  the  case  when  there  is  increase  of  air  in  the  part. 

Broadly  speaking,  therefore,  in  affections  of  the  lung  proper,  the 
two  conditions  just  mentioned  must  be  differentiated — air  increased, 
air  diminished.  We  do  not  refer  to  bronchitis,  because  no  physical 
change  takes  place  in  the  lung,  and  the  signs  depend  upon  the  amount 
of  fluid  in  the  tubes. 

The  Pleura.  If  satisfied  that  the  physical  condition  is  not  due  to 
change  in  the  lung  structure,  the  state  of  the  pleura  most  be  investi- 
gated. Here,  too,  the  physical  condition  may  be  due  to  an  excessive 
accumulation  of  air  or  to  an  accumulation  of  fluid  or  solid  material. 
In  effusion  there  is  enlargement  of  the  affected  side,  diminished  move- 
ment, diminution  of  fremitus  and  of  vocal  resonance.  Winn  air  i- 
present,  however,  there  is  tympany;  when  fluid,  there  i-  dulness  on 
percussion. 

The  problem  may,  however,  be  looked  at  from  another  side.  1. 
The  percussion-note  is  tympanitic  and  indicates  that  there  is  an  increased 


278  SPECIAL  DIAGNOSIS. 

amount  of  air.  Is  this  in  the  pleura  or  the  lung  ?  If  in  the  pleura, 
it  can  only  be  unilateral,  and  is  recognized  by  diminution  of  the  move- 
ment and  of  fremitus,  as  against  increased  movement  and  fremitus  when 
due  to  unilateral  increase  of  air  in  the  lung  proper  (compensatory  em- 
physema). 2.  The  percussion-note  is  dull  and  indicates  the  absence  of 
air.  Is  this  in  the  pleura  or  in  the  lung  ?  A  distinction  between  con- 
solidation and  pleural  effusion  must  be  made.  In  consolidation  there 
are  increased  fremitus,  increased  vocal  resonance,  bronchial  breathing, 
and  dulness  on  percussion.  (See  Fig.  46.)  There  may  or  may  not  be 
contraction.  In  pleurisy  with  effusion,  diminished  or  absent  movement, 
absent  fremitus  and  resonance,  dulness  on  percussion,  feeble,  distant, 
or  absent  breath-sounds.  (See  Fig.  47.)  The  distinction  of  the  two 
physical  conditions  seems  easy,  and  yet  the  physical  signs  may  not  be 
sufficiently  definite  to  warrant  a  positive  conclusion.  There  are  cases 
in  practice  in  which  it  is  almost  impossible  to  determine  which  is  pres- 
ent. It  has  been  stated  previously  that  bronchial  breathing  may  be 
present  in  pleural  effusions.  To  add  to  the  difficulty  in  certain  cases 
of  consolidation  it  may,  however,  be  absent  and  so  may  the  vocal  fre- 
mitus and  resonance.  Apart  from  the  associate  general  and  local  symp- 
toms, we  must  look  to  two  methods  of  corroborative  proof  of  the 
presence  of  fluid.  First,  exploratory  puncture;  and,  second,  displace- 
ment of  organs.  The  former  has  been  spoken  of.  The  latter  includes 
displacement  of  the  heart  to  the  right  or  the  left,  depending  upon  the 
seat  of  the  effusion;  dislocation  of  the  liver;  and,  in  cases  of  left 
pleural  effusion,  obliteration  of  the  half -moon  space  (Traube's  line). 

Sputum.  This  term  is  applied  to  all  the  products  of  secretion  of 
the  mucous  membrane  of  the  respiratory  tract,  and  other  substances 
that  may  be  brought  up  through  the  respiratory  tract.  The  characters 
of  sputa  in  disease  vary  with  the  part  affected,  as  well  as  with  the 
pathological  nature  of  the  disease.  It  is  always  well  to  examine  each 
specimen  both  macroscopicall y  and  microscopically. 

Method  of  Collection.  Sputum  that  is  to  be  examined  should  be 
collected  in  perfectly  clean  vessels,  containing  no  fluid,  preferably  in 
glass  or  white  earthenware  spittoons,  and  care  should  be  exercised 
against  the  eutrance  of  any  extraneous  substances,  as  tobacco  or  par- 
ticles of  food  from  the  mouth,  or  from  outside  sources,  or  from  the 
stomach  through  vomiting.  Tobacco,  prunes,  and  bread  crusts  are  at 
times  mistaken  for  blood.  It  is  also  necessary  to  see  that  the  matter 
sent  for  examination  is  derived  from  the  lungs,  and  is  not  simply  the 
oral  and  faucial  accumulation.  If  practicable,  the  mouth  and  pharynx 
should  be  first  rinsed  with  a  warm  alkaline  solution.  The  true  sputum 
is  coughed  up. 

We  usually  require  in  the  examination  one  or  two  glass  dishes  or 
plates,  a  large  and  a  small  piece  of  window-glass,  mounted  needles,  and 
forceps;  for  microscopic  work,  in  addition  to  these,  a  good  microscope 
and  accessories,  and  certain  staining  fluids. 

In  describing  sputum  we  note  the  quantity  in  twenty-four  hours,  its 
color,  odor,  specific  gravity,  its  composition  and  consistency,  whether 
mucous,  purulent,  muco-purulent,  frothy,  watery,  bloody,  tenacious  or 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  279 

viscid,   and  whether  it   is   made  up  of  separate  layers  or  is  homo- 
geneous. 

The  quantity  in  twenty-four  hours  varies  from  a  few  c.e.  to  even 
1000  c.c,  as  in  a  discharging  empyema. 

The  color  changes  with  the  composition  and  the  nature  of  the  dis- 
ease; thus,  in  acute  bronchitis  and  oedema  of  the  lung  it  is  white;  in 
purulent  sputa,  no  matter  what  the  cause,  it  is  yellow  or  greenish-yel- 
low; in  pneumonia,  "rusty;"  in  abscess  of  the  liver  with  amoeba 
characteristics,  brownish-red  or  like  "  anchovy  sauce." 

The  odor  is  characteristic  in  a  few  cases  only.  That  of  bronchi- 
ectasis, gangrene,  and  putrid  bronchitis  is  particularly  heavy  and  foetid, 
a  characteristic  which  renders  its  origin  almost  unmistakable. 

The  reaction  is  always  alkaline. 

The  specific  gravity  may  vary  from  1 .  0043  (mucous  sputum)  to 
1.0375  (serous).      (Von  Jaksch.) 

Varieties  of  Sputum.  Mucous  Sputum,  on  account  of  the  mucin, 
is  usually  glairy,  clear,  and  tough.  It  is  seen  in  acute  bronchitis  in 
the  early  stage,  and  in  oedema  of  the  lung.  In  health  a  small  amount 
of  mucus  is  expectorated,  which  in  cities  and  smoky  towns  is  apt  to 
contain  black  pigment-particles,  due  to  inhaled  soot. 

Purulent  Sputum  is  composed  almost  entirely  of  pus.  Typical  puru- 
lent sputum  is  that  from  an  empyema  discharging  through  a  bronchus. 
It  may  also  occur  in  bronchiectasis,  chronic  bronchitis,  abscess  of  the 
lung,  of  the  liver,  or  more  rarely  of  the  mediastinum,  discharging 
through  a  bronchus;  or  it  may  be  the  discharge  of  a  tubercular 
vomica.  The  special  condition  can  usually  be  determined  by  micro- 
scopical examination  and  the  accompanying  symptoms  and  signs. 

Muco-purulent  Sputum.  It  is  most  common  to  have  mucus  and  pus 
mixed  together  in  varying  proportions,  and  then  it  is  termed  muco- 
purulent. Such  sputa  may  be  found  in  the  same  conditions  as  purulent 
sputa.  When  flat,  coin-shaped  masses  are  formed,  sinking  to  the 
bottom  if  the  vessel  contains  water,  as  in  phthisis  and  chronic  bron- 
chitis, it  is  known  as  ' '  nummular ' '  sputum  ;  or  it  may  be  more  spher- 
ical, and  is  then  called  "  globular."  At  times  the  sputa  may  be  seen 
to  separate  into  three  distinct  layers,  the  upper  frothy,  muco-purulent, 
greenish-yellow,  or  dirty-green,  sometimes  lumpy,  sometimes  composed 
of  shreds;  the  middle  thin  and  watery,  with  shreds  from  the  upper 
layer;  and  the  bottom  layer,  apparently  made  up  of  pus  and  debris, 
opaque  and  without  air-bubbles.  It  points  to  gangrene  of  the  lung  in 
most  instances,  but  may  also  occur  in  bronchiectases. 

Watery  or  serous  sputum  is  the  result  of  oedema  of  the  lung. 

Bloody  Sputum — Haemoptysis.  As  blood  in  sputum  is  always  of 
importance,  the  entrance  of  substances  as  mentioned  above,  which  sim- 
ulate it  in  appearance,  should  be  guarded  against.  It  may  be  seeD  in 
greatly  varying  quantities  and  have  many  different  sources,  and  it  may 
be  of  slight  or  grave  significance.  It  may  come  from  the  gums,  nose, 
pharynx,  or  larynx,  and  in  all  eases  such  sources  should  be  examined. 
Again,  there  may  be  cases  in  which  bleeding  from  the  stomach  (hsema- 
temesis)  simulates  hemorrhage  from  the  lungs,  and  still  more  often 
people  speak  of  vomiting  blood  that  really  has  come  from  tlie   lungs. 


280  SPECIAL  DIAGNOSIS. 

Usually  that  from  the  lungs  is  much  more  frothy  and  bright  red,  while 
that  from  the  stomach  is  darker  and  acid,  and  may  contain  particles  of 
food.  Diagnosis  is  more  difficult  when  some  blood  from  the  lungs  is 
first  swallowed  and  then  vomited.  Usually  there  is  a  distinct  history 
of  preceding  cough,  and  for  some  time  afterward  small  amounts  of 
blood  continue  to  be  expectorated.      (See  Lungs  :  hemorrhage.) 

Small  amounts  of  blood  streaking  the  mucous  sputum  or  appearing 
in  small  clots  often  come  from  the  throat  or  nose  or  upper  air-passages, 
but  may  come  from  the  lungs.  Muco-purulent  sputum  streaked  with 
blood  is  frequently  indicative  of  phthisis.  In  pneumonia  the  rusty 
sputa  are  the  result  of  an  admixture  of  mucus  and  blood,  and  usually 
contain  small  air-bubbles.  When  the  blood- coloring  matter  is  changed 
there  may  be  a  yellowish  or  greenish  tinge.  In  certain  cases  of  chronic 
pneumonia,  in  which  the.  blood  remains  longer  in  the  lung-tissue,  the 
expectoration  has  a  darker  color.  The  same  color  may  be  observed  when 
there  is  slight  leakage  from  an  aneurism.  Pneumonia  accompanied  by 
expectoration  of  large  amounts  of  blood  is  often  of  tuberculous  origin. 
Blood  may  be  mixed  with  the  greenish  expectoration  of  gangrene. 
According  to  Finlayson,  this  is  especially  true  in  children.  In  chronic 
valvular  disease  of  the  heart,  and  in  oozing  from  aneurism,  frothy 
mucus  containing  more  or  less  blood  is  commonly  seen.  "  Currant- 
jelly"  sputa  are  more  or  less  characteristic  of  malignant  growths  of 
the  lungs,  while  the  expectoration  from  a  liver-abscess  with  amoebae  is 
reddish-brown  in  color,  from  the  mixture  of  blood,  pus,  and  bile- 
elements,  and  is  not  unlike  "  anchovy  sauce."  We  may  have  hemor- 
rhage from  the  lungs  as  part  of  a  general  hemorrhagic  tendency,  as 
in  purpura  and  hemorrhagic  smallpox;  in  so-called  "  vicarious  men- 
struation "  there  may  be  haemoptysis.  But  a  patient  presenting  such 
symptoms  should  be  examined  with  the  greatest  care  to  exclude  actual 
pulmonary  complication.  When  great  quantities  of  blood  are  expec- 
torated we  suspect  tuberculosis  of  the  lung,  aneurism,  or  cardiac 
valvular  disease. 

The  unaided  eye  may  distinguish  other  foreign  substances,  such  as 
fibrinous  and  spiral  casts  of  the  bronchi  or  trachea;  but  full  considera- 
tion of  them  will  be  giveu  further  on. 

Microscopic  Examination  op  the  Sputum.  (See  Fig.  56.) 
White  blood-corpuscles  are  present  in  all  sputa,  but  in  varying  numbers 
and  size.  They  are  most  abundant  in  purulent  sputa.  Often  they 
contain  fat-drops  and  pigment-particles. 

Red  blood- corpuscles  are  to  be  found  in  most  sputa.  They  may  be  so 
few  as  not  to  give  a  red  color.  The  source  is  often  high  up  in  the 
respiratory  tract.  When  they  are  present  in  large  numbers  the  spu- 
tum is  more  or  less  tinged,  and  in  haemoptysis  it  is  almost  wholly  made 
up  of  red  cells.  Usually  each  cell  is  well  preserved,  but  they  may 
appear  as  pale  bodies  or  as  rings,  the  -pigment  remaining  in  the 
sputum  as  pigment-particles  or  as  crystals  of  hsematoidin,  as  in  pneu- 
monia. 

Epithelium.  Two  general  varieties  are  found  in  the  sputum — squa- 
mous and  cylindrical.  The  former  comes  from  the  mucous  membrane 
of  the  mouth,  the  tongue,  tonsils,  true  vocal  cords,  and  perhaps  from 


DISEASES  OF  THE  LUNGS  AND  PLEURA. 


281 


the  salivary  and  small  bronchial  glands.    It  has  no  clinical  importance. 
(See  Fig.  56.) 

Cylindrical  cells  in  sputum  are  rarely  perfect.  It  is  uncommon  to 
find  the  cilia  intact,  and  still  more  so  in  motion,  while  the  body  of  the 
cells  is  likely  to  be  changed.  They  are  found  in  inflammations  of  the 
trachea  and  bronchi,  or  the  posterior  nasal  fossa — a  locality  where,  it 
must  be  remembered,  ciliated  epithelium  exists. 


Fig.  ."6. 


Various  objects  from  sputum.  1,  squamous  epithelium  ;  2,  red  blood-corpuscles  ;  3,  polynuclear 
leucocytes ;  4,  alveolar  cells ;  5,  myelin-cells ;  6,  pigment-cells ;  7,  elastic-tissue  fibres ;  8,  squa- 
mous cells  ;  9,  hsematoidin-crystals ;  10,  phosphate  crystals ;  11 ,  fungi  ;  12,  fat-globules  ;  13,  free 
pigment.    (Original  observation.) 

"Alveolar  "  epithelium,  so  called,  when  found  in  the  sputum,  is  more 
important  than  the  above,  as  different  observers  consider  its  presence 
to  have  more  or  less  clinical  significance.  The  cells  are  elliptical  or 
round,  somewhat  larger  than  white  corpuscles,  with  a  single  nucleus, 
which  is  indistinct  without  the  addition  of  acetic  acid.  The  proto- 
plasm is  granular  and  contains  particles  of  iron-dust,  carbon,  or  blood- 
coloring  matter,  and  often  fat-drops.  The  cells  may  also  have  under- 
gone complete  fatty  degeneration,  and  they  have  been  considered  the 
source  of  myelin-drops  in  the  sputum. 

Alveolar  epithelium  is  found  in  the  sputum  of  chronic  bronchitis, 
acute  and  chronic  pneumonia,  and  tuberculosis  of  the  lung. 

Detection.  A  small  bit  of  sputum  is  placed  on  a  microscope-slide 
and  a  cover-slip  applied.  Examine  with  varying  powers,  and  again, 
after  acetic  acid  is  added,  stain  the  cells  with  an  aqueous  solution  of 
mcthylene-blue. 

Elastic  fibre*.  As  the  presence  of  elastic  fibres  in  sputa  is  of  much 
import,  denoting  destruction  of  the  lung  tissue,  bronchi,  or  the  larynx 
or  bloodvessels,  their  presence  from  food  remaining  in  the  mouth  must 
be  especially  guarded  against.  They  may  be  mistaken  for  fat-crystals. 
They  are  found  as  single  threads  in  bundles,  or  showing  an  alveolar 
arrangement.  They  are  to  be  recognized  by  the  double  contour  and 
curling  ends,  aud  at  times  by  their  alveolar  arrangement.      They  may 


282 


SPECIAL  DIAGNOSIS. 


be  due  to  tuberculosis,  abscess  of  the  lung,  bronchiectasis,  gangrene  of 
the  lung,  pneumonia  (Von  Jaksch),  and  rarely  to  destructive  diseases 
of  the  larynx.  In  a  very  great  majority  of  cases  they  are  due  to  tuber- 
culosis. It  is  uncommon  to  find  them  in  gangrene,  probably  because, 
as  Traube  first  suggested,  they  are  destroyed  by  a  ferment.  (Fig.  57.) 
Elastic  tissue  from  the  alveoli  often  shows  the  diagnostic  alveolar 
arrangement;  the  fibres  that  form  a  bronchus  are  branched;  those  from 
eroded  artery  appear  in  the  form  of  a  network,  or  the  fibres  are  bound 
together. 

Fig.  57. 


Elastic  fibres  of  lung-tissue  obtained  from  sputa  after  digestion  in  caustic  soda. 
(Drawn  by  Dr.  John  Wilson.) 

Detection.  The  method  employed  by  Osier,  modified  from  Sir 
Andrew  Clark's,  is  the  best.  A  small  amount  of  the  thick,  puru- 
lent portions  of  sputum  is  pressed  out  in  a  thin  layer  between  two 
pieces  of  plain -window-glass,  15  x  15  cm.  and  10  x  10  cm.  The  par- 
ticles of  elastic  tissue  appear  on  a  black  background  as  grayish-yellow 
spots,  and  can  be  examined  in  situ  under  a  low  power.  Or  the  upper 
piece  of  glass  is  slid  off  till  the  piece  of  tissue  is  uncovered,  when  it  is 
picked  out  and  examined  on  a  microscopic  slide,  first  with  a  low 
power,  as  the  one  or  one-half  inch  objective,  and  then  with  a  higher 
power.  At  first  there  will  be  some  difficulty  in  distinguishing  with 
the  naked  eye  between  elastic  fibres  and  particles  of  bread  or  milk 
globules,  or  collections  of  epithelium  and  debris,  but  with  practice 
such  mistakes  can  be  avoided,  and  the  microscope  always  reveals  the 
difference.  This  method  is  much  easier  of  accomplishment  and  quite 
as  satisfactory  in  results  as  the  one  generally  employed — boiling  an 
equal  quantity  of  sputum  and  solution  of  caustic  potash  (8  to  10  per 
cent.)  lor  a  short  time,  and  allowing  it  to  stand  for  twenty-four  hours 
in  a  conical  glass.  The  elastic  tissue  remains  intact  and  is  found  in 
the  sediment. 

Connective  tissue  and  cartilage,  in  fragmentary  bits,  are  rare  constit- 
uents of  sputum.  The  former  may  occur  with  abscess  or  gangrene  of 
the  lung,  and  the  latter  when  there  is  ulceration  of  the  larynx. 

Fibrinous  Coagula.  These  striking,  tree-like  bodies  are  found  in 
the  sputa  of  plastic  bronchitis,  and  at  times  in  that  of  pneumonia, 
phthisis,  and  in  diphtheria  and  croup  when  there  has  been  an  extension 


DISEASES  OF  THE  L  UXGS  AND  PLE  UBJE.  283 

into  the  bronchi.  They  are  usually  mixed  with  mucus  and  are  rolled 
up  into  a  mass.  Their  peculiar  form  is  best  seen  when  they  are  washed 
and  unravelled  in  water.  They  are  then  seen  to  be  a  complete  mould 
of  a  small  bronchus  with  its  ramifications.  The  size  varies  greatly. 
They  may  be  many  centimetres  long.  In  fibrinous,  bronchitis  the  size 
and  shape  of  the  moulds  in  different  attacks  may  be  exactly  similar, 
as  if  they  came  from  the  same  bronchus.  They  are  grayish- white  in 
color,  hollow,  and  on  transverse  section  are  seeu  to  be  made  up  of  cast 
upon  cast.  Leucocytes,  blood-cells,  and  alveolar  epithelium  are  found 
in  the  meshes  by  the  microscope,  and  at  times  Charcot-Leyden  crystals 
and  Curschmann's  spirals  also.  They  are  almost  pathognomonic  of 
fibrinous  bronchitis.  When  they  occur  in  any  number  in  pneumonia 
they  make  the  prognosis  unfavorable.  Blood-casts  of  the  smaller 
bronchi  have  been  found  in  cases  of  haemoptysis.  They  are  rare,  and 
have  no  apparent  connection  with  the  fibrous  coagula. 

Spirals.  Under  this  name  are  included  spiral  bodies  that  are  found 
in  the  sputa  of  bronchial  asthma,  and  occasionally  in  that  of  pneu- 
monia and  capillary  bronchitis  (Von  Jaksch),  and  chronic  pulmonary 
tuberculosis  (Vierordt).  At  the  beginning  of  an  asthmatic  attack 
tough  rounded  balls  are  expectorated — " perles"  of  Laennec,  which, 
if  freed  from  the  mucus  surrounding  them  and  spread  out  on  a  glass 
with  a  dark  background,  may  be  seen  by  the  naked  eye  to  have  a 
twisted  spiral  form.  With  the  aid  of  the  microscope  they  are  found 
to  be  made  up  of  spirally  arranged  mucin  in  a  more  or  less  tight  twist, 
with  many  cells  from  the  alveoli  and  bronchi.  In  some  of  these 
spirals  a  shining  central  thread  runs  through  the  entire  length  like  a 
core,  remarkable  for  its  clearness  and  its  high  refractive  index.  The 
fine  fibres  composing  the  spiral  may  be  closely  arranged  or  not.  Epithe- 
lium and  Charcot-Leyden  crystals  may  be  found  lying  among  the  coils. 
The  main  constituent  of  the  spirals  is  mucin,  and  Osier  has  suggested 
that  the  central  thread  is  made  up  of  transformed  mucin.  On  the  other 
hand,  Von  Jaksch  believes  it  to  be  chemically  distinct  from  the  mucin 
spiral.  Vierordt  considers  it  either  made  of  tightly  twisted  central 
fibres  or  to  be  an  optical  image  of  a  core-cavity.  They  are  probably 
the  result  of  an  acute  bronchiolitis.  Why  they  should  assume  this 
remarkable  form  is  still  an  open  question.  It  has  been  suggested 
(Osier)  that  the  ciliated  epithelium  of  the  bronchi  may  have  a  rotary 
action,  and  their  action,  combined  with  the  spasm  of  the  bronchioles, 
causes  the  spiral  formation. 

Sections  for  3Iicroscopical  Examination.  Schmidt  (Zeitsch rift  fur 
Min.  Med.,  1892,  p.  476)  fixes  sputum  in  one-half  per  cent,  salt  solu- 
tion saturated  with  mercuric  chloride,  hardens  in  alcohol,  and  sections 
in  the  usual  manner.  In  many  cases  it  is  advisable  to  roll  up  the 
sputum  in  a  little  ball  before  fixation.  For  the  study  of  spirals  thick 
pieces  should  be  imbedded  in  celloidin;  for  the  study  of  the  cellular 
elements  thin  sections  are  imbedded  in  paraffin. 

Sections  of  sputum  with  mucin  swell  when  treated  with  watery  solu- 
tions of  the  dyes;  hence  the  celloidin  should  be  firs!  removed  to  prevent 
folding  of  the  sections.  All  specimens  of  sputum,  except  the  very 
thin  ones,  can  be  prepared  in  the  manner  described. 


284 


SPECIAL  DIAGNOSIS. 


The  spirals  are  best  stained  with  Weigert's  fibrin-method;  they  stain 
blue.  Yet  they,  i.e.,  the  central  thread,  are  not  fibrin:  (1)  because  they 
are  perfectly  homogeneous;  (2)  they  assume  a  violet  color  after  pro- 
longed staining — fibrin  is  always  blue;  (3)  unformed  blue  masses  are 
found  which  could  only  be  compact  mucin  masses;  (4)  their  specific 
mucin  reaction  with  thionin;  (5)  the  greenish  color  assumed  when 
Ehrlich's  triacid  stain,  as  modified  by  Babes,  is  used. 


Fig 


X  30G. 


»>:- 


Spirals  from  bronchial  tubes.    X  80.    (After  Leyden.) 


That  there  is  a  connection  between  the  spirals  and  Charcot-Leyden 
crystals  seems  very  probable,  as  the  latter  are  absent  from  the  sputum 
at  the  beginning  of  an  attack  of  bronchial  asthma;  but  if  a  portion  of 
such  sputum  is  allowed  to  stand  for  twenty -four  to  forty-eight  hours, 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


285 


taking  care  that  evaporation  does  not  take  place,  crystals  will  be  fouDd. 
As  has  been  said,  the  crystals  are  often  found  among  the  spirals,  and 
this  when  they  are  seen  nowhere  else.  Later  on  the  spirals  disappear, 
but  crystals  derived  from  them(?)  continue  to  be  expectorated  (see 
Fig.  58). 

The  method  of  examining  for  spirals  is  as  given  above. 

Crystals.  Charcot-Leyden,  cholesterin,  hsematoidin,  fatty,  tyro- 
sin,  oxalate  of  lime,  and  triple  phosphate  crystals  are  to  be  found  in 
sputa  under  various  conditions. 

Charcot-Leyden  crystals  are  octahedral,  sharply  pointed,  colorless 
or  slightly  bluish,  soluble  in  warm  water,  alkalies,  and  acetic  and  min- 
eral acids.  The  practised  unaided  eye  may  recognize  these  as  small 
yellowish  bodies,  not  unlike  grains  of  sand ;  under  the  microscope  they 
are  unmistakable.  Their  size  varies  greatly.  They  occur  most  abun- 
dantly during  (invariably)  and  after  an  attack  of  bronchial  asthma; 
they  have  also  been  seen  in  sputa  of  acute  and  chronic  bronchitis  and 
tuberculosis.  They  are  identical  with  crystals  found  in  semen,  faeces, 
and  in  leukaemic  blood  and  bone-marrow.  Their  connection  with 
spirals  has  been  mentioned  above.  Schreiner  considers  them  to  be 
the  phosphate  of  an  unknown  base,  which  Ladenburg  and  Abel  think 
may  be  identical  with  ethyl  eninim.      (Von  Jaksch.) 

Detection.  Examine  the  sputum  of  an  asthmatic  patient  a  day  or 
two  after  the  beginning  of  an  attack  for  round,  hard,  yellowish  bodies, 
and  place  these  under  the  microscope  with  different  powers  They 
are  readily  recognized.  (See  p.  59.) 

Fig.  59. 


Charcot  crystals.    (Scheube.) 

CholesteHn-cry  state.  These  crystals  are  similar  to  those  of  choles- 
terin found  elsewhere,  being  thin  rhombic  plates,  often  with  irregular 
corners  and  high  refractive  index.  They  are  soluble  in  ether;  and, 
when  treated  with  dilute  sulphuric  acid  and  tincture  of  iodine,  become 
violet,  blue,  or  green,  and  then  red.  They  may  be  present  in  the 
sputum  of  tuberculosis,  abscess  and  hydatid  abscess  of  the  lung,  and 
in  pus  from  an  abscess  of  another  organ,  as  the  liver.  They  have 
but  little  clinical  significance. 

Hcematoidin-cry state.  Haematoidin-crystals  are  at  times  recognizable 
by  the  naked  eye  as  distinct  spots  of  yellowish  or  brownish-red  color. 
Under  the  microscope  they  have  a  brownish-yellow  or  ruby-red  color, 


286  SPECIAL  DIAGNOSIS. 

and  are  either  iu  the  forni  of  small  rhomboid  prisms  or  of  fine  needles, 
single  or  arranged  in  bunches  of  various  shapes,  or  as  free  pigment- 
particles  'without  crystalline  form;  smaller  particles  may  be  contained 
within  a  leucocyte.  Their  presence  indicates  that  blood  has  remained 
in  the  respiratory  tract  for  some  time  before  being  expectorated,  or  that 
an  abscess  has  discharged  into  a  bronchus.  They  occur  in  phthisis, 
following  hemorrhage;  in  thoracic  aneurism  when  blood  is  oozing  into 
the  lung;  in  gangrene;  in  abscesses  discharging  through  a  bronchus. 
Von  Jaksch  states  that  when  the  crystals  are  contained  in  cells  there 
has  been  a  preceding  hemorrhage,  but  that  when  there  is  considerable 
free  hsematoidin  one  infers  that  an  abscess  of  a  neighboring  organ  has 
discharged  into  the  lung. 

Fatty  crystals.  Crystals  of  margaric  acid  occur  as  long,  thin  needles, 
gently  curved  or  bent  at  one  end  like  a  fish-hook,  and  either  singly  or 
in  bundles.  They  are  found  in  unhealthy  pus — as  in  gangrene,  putrid 
bronchitis,  bronchiectasis,  and  tuberculosis;  in  the  plugs  formed  in 
inflamed  tonsils;  and  in  purulent  sputum  in  general  which  is  allowed 
to  stand  in  a  warm  place.  They  dissolve  in  ether  and  boiling  alcohol; 
this  characteristic,  together  with  the  regularity  of  their  curve,  should 
distinguish  them  from  elastic  fibres,  with  which  they  are  sometimes 
confused  by  beginners. 

Tyrosin-crystals  have  been  found  in  the  sputum  of  putrid  bronchitis 
and  empyema  discharging  into  the  lung,  and  usually  in  conjunction  with 
leucin.  They  are  most  abundant  in  sputum  that  has  been  allowed  to 
stand  for  some  time.  Under  the  microscope  they  appear  as  fine  needles 
and  can  be  mistaken  for  fatty  crystals.  They  are  without  diagnostic 
importance. 

Oxalate  of  Lime  and  Triple  Phosphates  have  been  noted  occasionally 
iu  sputa;  the  former  in  a  case  of  diabetes,  and  also  in  an  asthmatic;  the 
latter  occur  only  in  alkaline  sputa,  as  they  are  soluble  in  acids. 

Corpora  Amylacea.  Starch-like  bodies  have  been  found  in  the 
sputum  after  pulmonary  hemorrhage,  and  in  that  of  pulmonary  gan- 
grene. They  have  the  shape  of  starch-corpuscles,  and  sometimes  give 
the  amyloid  reaction  with  iodine  or  iodide  of  potassium.  They  are  at 
present  without  clinical  significance. 

Parasites.  A.  Animal  Parasites.  Echinococcus  cysts  are  to 
be  found  in  sputum,  generally  broken  into  fragments,  and  only  very 
rarely  in  a  perfect  whole,  when  there  is  rupture  of  a  cyst  of  the  liver 
or  lung  into  a  bronchus.  Scolices  and  free  booklets  from  the  same 
may  be  recognized,  and  pieces  of  the  cyst-wall  wrill  be  known  by  their 
remarkable  formation.      Their  presence  is  of  great  clinical  value. 

Infusoria  have  been  found  in  the  expectoration  from  gangrene  of  the 
lungs.      They  belong  to  the  monad  and  cercomonad  varieties. 

Distoma  haematobium  eggs  may  occur  in  sputa  when  the  lung-tissue 
is  broken  down  by  its  presence,  the  eggs  being  thrown  off  in  the 
sputum. 

Amoeba  Dysenteric,  (Amoeba  Coli).  Of  far  more  interest  and  impor- 
tance is  the  presence  of  this  parasite  in  the  expectoration.  A  full 
description  of  the  amoeba  will  be  given  in  the  chapter  on  the  Faeces. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  987 

They  are  the  same  in  every  respect  when  found  in  the  sputum,  except 
that  they  are  often  slightly  larger.  The  sputum  containing  the  amoeba 
is  partly  diffluent,  tenacious,  frothy,  bright  red  in  color  at  first,  due  to 
the  presence  of  blood,  and  later  brick  or  brownish-red,  sometimes  bile- 
stained.  Small  yellowish-white  cheese-like  particles  are  seen.  Upon 
exposure  to  the  air  the  sputum  becomes  thin,  syrupy,  and  oily,  and  it 
then  looks  much  like  anchovy  sauce.  The  sputa  are  alkaline  and  of 
a  faintly  sweetish  odor,  never  putrid.  Later  on  they  become  more 
purulent,  somewhat  nummular,  reddish-yellow,  and  contain  less  blood. 
If  there  is  a  favorable  termination,  they  become  more  fluid  and  frothy, 
with  less  blood  and  pus,  and,  on  standing,  show  the  three  layers.  The 
quantity  varies  from  25  c.c.  to  500  c.c.  in  twenty-four  hours.  Under 
the  microscope  will  be  found,  beside  the  amoeba,  red  blood-corpuscles, 
leucocytes,  alveolar  and  oval  epithelium,  and  bodies  looking  like  degen- 
erated liver-cells  without  a  nucleus;  occasionally  elastic  fibres,  hsema- 
toidin,  leucin,  tyrosin,  and  Charcot-Leyden  crystals  and  bacteria  are 
seen.  The  cheesy  particles  are  made  up  of  amorphous  granular  mat- 
ter and  oil-globules.  Amoebae  are  constantly  present  in  varying 
numbers,  usually  not  so  many  as  in  the  stool,  but  somewhat  larger. 
The  number  varies  from  day  to  day,  and  diminishes  with  the  dis- 
appearance of  the  cough  and  expectoration.  The  sputa  should  be  ex- 
amined as  soon  after  their  discharge  as  possible,  and  in  the  interim 
should  be  kept  at  a  temperature  of  30°  to  35°  C.  If  examined  on  a 
warm  stage,  active  movements  of  the  amoebae  will  be  kept  up  much 
longer. 

They  should  be  examined  under  various  powers  :  ^,  \  or  \,  and  y1^ 
inch  objectives.  Of  these  the  \  or  T  inch  will  be  found  most  suitable 
for  following  the  movements.  They  measure  from  10//  to  20//.  They 
will  be  readily  recognized  by  their  size,  formation,  and  movements. 
(See  Faeces  for  further  description.)  That  they  have  important  clin- 
ical value  is  true,  as  cases  have  been  reported  in  which  the  observer 
diagnosticated  hepatic  or  hepato-pulmonary  abscess  secondary  to  amoebic 
dysentery,  by  the  peculiar  anchovy-sauce  expectoration  and  subsequent 
detection  of  the  amoebae. 

B.  Vegetable  Parasites.  Fungi — Non-pathogenic:  Moulds. 
O'idium  albicans  may  be  a  constituent  of  the  sputum  when  the  bronchi 
are  invaded  by  it,  but  usually  it  is  from  the  saliva.  Certain  other 
moulds  have  lately  been  considered  to  cause  disease  of  the  lungs  by 
multiplication,  but  nothing  very  definite  has  resulted  from  the  experi- 
ments thus  far  made. 

Yeast-fungi.  Von  Jaksch  reports  having  seen  scattered  yeast-cells 
in  the  pus  from  a  phthisical  cavity.  Otherwise  we  have  no  knowledge 
of  yeast  being  found  in  sputa. 

Fission-fungi.  Leptothrix.  Leptothrix  occurs  alone,  in  the  sputum 
or  in  the  bronchial  plugs,  in  putrid  bronchitis,  along  with  fatty  acid 
and  haematoidin-crystals.  It  is  probably  derived  from  the  mouth, 
having  thence  entered  the  air-passages,  or  it  is  taken  up  from  the  mouth 
by  the  expectoration.  It  is  recognized  by  its  staining  blue  with  iodine 
and  potassium  iodide. 

Sarcince  pulmonalis.    Sarcinae  may  be  seen  in  sputa.     They  are  larger 


288  SPECIAL  DIAGNOSIS. 

than  sarcinse  ventriculi,  with  which  they  have  no  connection,  nor  have 
they  pathological  significance  when  present  in  sputa. 

Non-pathogenic  bacilli  and  cocci  may  occur  in  all  sputa,  but  are  with- 
out significance.  They  are  more  numerous  in  foetid  sputa.  They  stain 
with  methylene-blue  and  other  simple  dyes. 

Pathogenic,  Fungi.  Tubercle  Bacillus.  The  organism  which  is  the 
cause  of  tuberculosis  is  a  rod,  straight  or  slightly  curved,  without 
motion,  varying  in  length  from  2p.  to  bp.  (about  J  to  J  the  diameter  of 
a  red  corpuscle).  It  usually  has  a  beaded  appearance  when  stained, 
due  to  the  spores,  which  do  not  take  up  the  stain  that  affects  the  rod 
as  a  whole,  and  which  often  bulge  slightly  beyond  the  edge.  It  is 
probable  that  this  beaded  appearance  is  caused  by  the  contraction  and 
breaking  up  of  the  stainable  portion,  permitting  us  to  see  the  empty 
spaces  between  the  fragments  and  the  other  membrane.  Bacilli  pre- 
senting this  appearance  are  supposed  to  be  undergoing  degeneration. 
The  bacillus  of  tuberculosis  cannot  be  recognized  in  the  sputum  unless 
stained,  and  in  the  staining  it  shows  a  peculiarity  which  belongs  to 
only  one  other  organism — the  bacillus  of  leprosy.  As  under  ordinary 
conditions  this  latter  bacillus  is  not  met  with,  this  peculiarity  in  stain- 
ing is  diagnostic  of  tubercle  bacilli. 

Preparation  of  Sputum  and  Method  of  Staining  Tubercle  Bacilli. 
A  small  amount  of  the  purulent  portion  of  the  sputum  is  spread  in- a 
thin  and  uniform  layer  on  a  perfectly  clear  cover-glass  by  means  of 
forceps,  needles,  or  the  "  Oese,"  which  must  previously  be  held  a 
moment  in  the  flame  of  a  Bunsen  burner  or  spirit  lamp;  or  by  press- 
ing a  small  amount  of  sputum  between  two  cover-glasses,  then  sliding 
them  apart.  It  is  then  dried  in  the  air,  or  more  quickly  by  holding 
the  cover-glass  with  forceps  some  distance  above  the  flame  of  a  burner 
or  lamp.  Finally,  it  is  to  be  passed  three  or  four  times  through  the 
flame,  and  so  "  fixed."  The  edge  of  the  cover-glass,  with  sputum 
side  up,  is  then  grasped  with  forceps  and  covered  with  the  staining  solu- 
tion, care  being  taken  to  prevent  the  fluid  from  extending  to  the  under 
surface,  and  held  in  or  j  ust  above  the  flame,  until  the  solution  boils  for 
a  second  or  two,  or  a  bubble  rises.  When  the  excess  of  the  solution 
is  washed  off  in  water,  the  slip  is  treated  with  the  decolorizing  agent 
until  the  color  is  almost  or  wholly  removed.  It  is  again  washed  in 
water  to  remove  the  excess  of  the  decolorizer,  and  mounted  for  exam- 
ination, or  given  a  contrast-stain;  the  latter  is  preferable. 

A  second  rapid  method  is  as  follows:  Select  with  the  sterilized  oese  a 
suspicious  yellowish  particle  from  the  sputum;  smear  it  thinly  over  one 
end  of  a  slide  which  has  been  previously  passed  several  times  through 
the  flame  of  an  alcohol  lamp  or  Bunsen  burner.  Dry  by  holding  over 
flame;  fix  by  passing  several  times  through  the  flame.  Cover  the  dried 
sputum  with  the  desired  stain,  and  steam  gently  for  two  minutes  over 
the  alcohol  or  low  Bunsen  flame;  the  slide  cau  be  held  in  the  fingers, 
or  after  heating  can  be  laid  aside  for  a  moment;  wash  off  the  excess 
of  stain  with  water,  then  cover  the  stained  sputum  with  decolorizing 
agent  and  counter-stain,  which  should  not  remain  more  than  thirty 
seconds.  Wash  away  excess  with  water,  dry  the  slide  by  blowing  upon 
it  through  a  pipette,  and  cover  with  a  clear  cover-glass,  using  distilled 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  289 

water  as  a  mount.  This  method  is  extremely  satisfactory  for  ordinary 
clinical  work,  especially  with  Ziehl'  s  and  Gabbett'  s  solution. 

If  fuchsin  has  been  used  to  stain  the  tubercle  bacilli,  methylene-blue 
is  a  good  contrast-stain;  while  if  gentian- violet  was  selected,  Bismarck- 
brown  is  better  in  contrast.  These  contrast-stains  are  made  as  needed 
by  dissolving  enough  of  the  dye  in  a  few  c.  c.  of  water  to  make  the  solu- 
tion as  seen  through  a  test-tube  of  14  mm.  diameter  only  transparent, 
and  then  filtering;  or,  a  concentrated  watery  solution  may  be  made  for 
stock  just  as  the  concentrated  alcoholic  solutions  of  fuchsin  and  gentian- 
violet  were  made,  diluting  a  small  quantity  of  this  when  needed  with 
enough  distilled  water  to  make  it  just  transparent  in  a  similar  test-tube. 
To  apply  the  contrast- stain,  place  a  few  drops  on  the  cover- glass  that 
has  been  prepared  as  above — stained,  decolorized,  and  washed — allow  it 
to  remain  thirty  or  forty  seconds,  wash  off  in  water,  and  mount 
for  examination  on  a  glass  slip,  in  water,  oil  of  cloves,  or  Canada 
balsam.  A  drop  of  water  will  serve  perfectly  well  for  examining 
when  the  preparation  is  not  to  be  preserved.  In  the  microscopic 
examination  use  a  y1^-  inch  oil-immersion  lens  and  Abbe  condenser,  or, 
at  the  least,  a  \  or  \  inch  objective.  If  gentian- violet  has  been  used, 
the  tubercle  bacilli  appear  as  dark-blue  rods,  with  all  other  bodies 
brown,  if  Bismarck-brown  is  used  for  contrast- stain;  while  with  fuchsin 
staining  for  tubercle  bacilli,  and  methylene-blue  as  a  contrast,  the  for- 
mer will  be  found  as  red  rods  in  a  blue  field  (background)  (see  Plate 
III.,  Fig.  1). 

The  above  rapid  method  of  staining  takes  much  less  time  than  the 
method  usually  described,  and  gives  most  satisfactory  results.  The 
steps  in  the  old  method  are  the  same  as  given  above,  except  that  instead 
of  placing  the  staining  solution  on  the  smeared  and  dried  cover-glass, 
and  holding  it  in  or  above  the  flame  until  the  solution  boils,  the  cover- 
glass  is  floated  in  a  cold  solution,  in  a  watch-glass,  sputum  side  down, 
for  twenty-four  hours,  or  in  a  hot  solution  for  six  to  eight  minutes,  or 
until  moisture  appears  on  the  upper  surface  of  the  cover-glass.  The 
remaining  steps  are  similar. 

Tubercle  bacilli  do  not  stain  with  the  simpler  dyes,  but  when  stained 
by  solutions  of  dyes  made  more  penetrating  by  the  addition  of  aniline 
oil,  carbolic  acid,  or  like  substances,  they  retain  the  color  token  subjected 
to  decolorizing  agents.  In  this  they  differ  from  all  other  organisms, 
except,  as  stated,  the  bacillus  of  leprosy. 

A  number  of  methods  have  been  devised  for  the  detection  of  this 
bacillus  by  means  of  its  peculiar  action  toward  stains.  The  most  sat- 
isfactory are  those  known  as  the  Koch-Ehrlich,  Ziehl-Neelson,  Gabbett, 
and  Gibbes.  These  methods  differ  chiefly  in  the  solutions  used. 
Slightly  modified  from  the  original  in  execution,  they  are  as  follows  : 

A.   Koch-Ehrlich  method. 

Solutions  Used. 
I.  Concentrated  alcoholic  solution  of  fuchsin  or  gentian-violet. 
II.  Saturated  solution  of  aniline  oil  in  water. 
III.  Thirty  per  cent,  solution  of  nitric  acid  in  water  (decolorizing  solution). 

I.  Place  in  a  clear  bottle  fuchsin  or  gentian-violet  in  substance  to 

one-fourth  its  capacity,  and  fill  with  alcohol  (95  percent.);  shake  well 

19 


290  SPECIAL  DIAGNOSIS. 

and  cork  and  allow  to  stand  for  twenty-four  hours.  If  all  of  the  dye 
has  been  dissolved,  add  more  and  shake,  and  stand  for  another  twenty- 
four  hours,  and  so  on  until  some  of  the  dye  remains  permanently 
undissolved  at  the  bottom  of  the  bottle.  This  solution  remains  good 
until  used. 

II.  To  about  100  c.c.  of  distilled  water  in  a  flask  or  other  suitable 
vessel,  add  aniline  oil,  drop  by  drop,  shaking  the  flask  continuously, 
until  the  solution  is  opaque,  or  drops  of  the  oil  float  on  the  surface, 
then  filter  through  moist  filter-paper  until  the  filtrate  is  perfectly  clear. 
This  solution  must  be  made  fresh  as  needed. 

III.  Mix  a  few  c.c.  of  nitric  acid  and  water  in  about  the  above 
proportion,  never  stronger,  each  time  bacilli  are  to  be  stained. 

The  Koch-Ehrlich  solution  is  made  by  adding  11  c.c.  of  the  fuchsin 
or  gentian  solution  (No.  I.),  and  10  c.c.  of  absolute  alcohol  to  100  c.c. 
of  the  clear  aniline  filtrate  (No.  II.).  It  should  not  be  used  after 
it  is  a  week  old. 

B.  Ziehl-Neelsen  method. 

Solutions  Used. 
I.  Carbolie-fuchsin  solution  : 

Distilled  water 100  c.c. 

Carbolic  acid  (crystalline) 5  grammes. 

Alcohol 10  c.c. 

Fuchsin  in  substance 1  gramme. 

This  solution  can  also  be  prepared  by  adding  saturated  alcoholic  solu- 
tion of  fuchsin  (see  above)  to  a  5  per  cent,  watery  solution  of  carbolic 
acid  until  a  metallic  lustre  is  seen  on  the  surface  of  the  fluid.  This 
solution  does  not  decompose  so  easily  as  those  made  with  aniline  oil. 

II.  Decolorizing  solution  of  nitric  acid,  and 
III.  Contrast  stain  of  methylene-blue,  as  above. 

The  preparation  and  staining  are  exactly  the  same  as  in  method  A. 
The  tubercle  bacilli  are  stained  red,  the  other  bodies  blue. 

C.  Gabbett's  method. 

Solutions  Used. 

I.  Carbolie-fuchsin  solution  (as  in  B). 
II.  Methylene-blue  solution  : 

Methylene-blue1 2  grammes. 

Sulphuric  acid 25  c  c. 

Distilled  water 75  c.c. 

This  solution  is  apt  to  decompose  if  old. 

Preparation  of  Slips  and  Staining.  The  cover-glass  is  prepared  and 
stained  with  the  carbolie-fuchsin  solution  and  washed  in  water  as  in  A. 
Then  (instead  of  decolorizing  with  nitric  acid  or  adding  in  contrast- 
stain)  the  slip  is  washed  for  twenty  to  thirty  seconds  in  the  methylene- 
blue  solution,  until  a  faint  blue  replaces  the  red  tinge  in  the  (slip) 
sputum;  the  excess  of  the  solution  is  Avashed  off  with  water,  and  the 
slip  is  mounted  and  examined  as  above.  The  tubercle  bacilli  are 
stained  red  and  the  other  bodies  blue. 

The  writer  has  found  that  this  method  can  be  rapidly  applied,  and 
that  it  gives  good  results;  he  recommends  it  highly. 

1  An  alcoholic  solution  of  methyl-blue  should  first  be  made,  and  then  added  drop  by  drop,  with 
constant  stirring,  to  the  sulphuric  acid  and  water. 


DISEASES  OF  THE  LUNGS  AND  PLEUBM.  291 

D.   Gibbes'  method. 

Solutions  Used. 

I.  a.  Fuchsin 3  grammes. 

Methylene-blue 1  gramme. 

Mix  thoroughly  in  a  mortar. 

b.  Aniline  oil 5  c.c. 

Alcohol 20  c.c. 

Dissolve  and  add  6  to  a  slowly,  stirring  vigorously  until  a  is  evi- 
dently dissolved,  then  add  20  c.c.  of  distilled  water,  and  keep  in  a 
stoppered  bottle,  ready  for  use. 

Prepare  slip  and  stain  with  this  solution,  as  with  the  others,  up  to 
the  point  of  decolorizing.  Then  wash  with  alcohol  until  the  dye  ceases 
to  come  away.  Mount  and  examine  as  above.  Tubercle  bacilli  will 
be  stained  dark  red — the  other  objects  dark  blue. 

When  the  bacilli  are  few  in  number,  Biedert  proposes  that  the  fol- 
lowing preliminary  steps  be  taken  :  About  4  c.c.  of  sputum  are  mixed 
with  8  c.c.  of  water  and  1  c.c.  of  solution  of  caustic  soda,  and  boiled 
a  few  minutes,  when  about  15  c.c.  of  water  are  added  and  the  whole 
again  boiled  until  a  homogeneous  fluid  is  formed.  This  is  allowed  to 
stand  in  a  conical  glass  for  twenty-four  to  forty -eight  hours,  when  the 
sediment  is  stained  by  the  Ziehl-Neelsen  or  Gabbet  method.  Or,  the 
homogeneous  fluid  can  be  put  at  once  in  a  centrifugal  machine,  and  the 
resulting  sediment  stained. 

Sputa  have  been  hardened  and  sections  made  and  stained  for  tubercle 
bacilli,  but  the  method  is  not  of  special  value. 

It  is  well  to  remember  that,  in  the  absence  of  a  proper  decolorizing 
agent,  hot  water  applied  for  some  minutes  has  been  shown  to  decolorize 
very  satisfactorily. 

Importance.  The  greatest  importance  attaches  to  the  presence  or 
continuance  of  tubercle  bacilli  in  sputa.  It  indicates  tuberculosis  of 
the  lung  or  larynx;  in  the  vast  majority  of  cases,  of  the  former. 

They  are  often  to  be  found  in  the  sputum  when  physical  signs  are 
not  yet  present,  or  are  indefinite.  The  number  varies  so  greatly  in 
different  cases,  and  in  the  same  case  at  different  times,  that  in  recent 
cases  it  is  impossible  to  judge  of  the  extent  of  the  disease  by  the  num- 
ber present  in  a  given  preparation.1 

The  absence  of  bacilli  from  sputa  has  no  true  value  unless  negative 
results  are  obtained  after  many  trials  and  careful  examination  by  an 
experienced  observer,  using  good  stains.  Hence,  too  great  care  cannot 
be  taken  in  each  and  every  step. 

Biological  Properties.  The  tubercle  bacillus  is  difficult  to  cultivate, 
as  it  grows  readily  only  in  conditions  found  within  the  body.  The  best 
medium  is  blood-serum.  The  cheesy  mass  from  the  sputum  or  the 
tubercular  nodule  from  a  tissue  is  placed  on  the  surface  of  the  serum 
and  rubbed  carefully  over  it.  It  is  best  to  make  twenty  or  thirty  such 
inoculations.  The  tubes  must  then  be  sealed  to  prevent  evaporation 
and  drying,  and  exposed  for  twelve  days  to  a  temperature  of  37.5°  C. 
When  a  pure  culture  is  obtained,  further  cultivations  may  be  made  on 
agar-agar  to  which  6  per  cent,  of  glycerin  has  been  added. 

i  A  Method  for  the  Examination  of  the  Actual  Number  of  Tubercle  Bacilli  in  Tuberculous 
Sputum.  By  George  H.  P.  Nuttall,  M.D.,  Ph.D.,  The  Johns  Hopkins  Hospital  Bulletin,  May,  1891. 
The  method  is  of  pathological  but  not  of  diagnostic  interest. 


292  SPECIAL  DIAGNOSIS. 

The  pure  cultures  appear  as  dry  masses  on  the  surface  of  the  medium, 
either  as  flat  scales  or  clumps  of  mealy-lookiug  granules.  They  are 
of  a  dirty  drab  or  brownish-gray  color  (see  Plate  I.,  Fig.  6).  The 
bacillus  is  parasitic,  aerobic,  non-motile  (facultative  anaerobic). 

Micrococcus  Lanceolatus.  Pneumococcus.  Diplococcus  Pneumoniae. 
The  causative  factor  of  croupous  pneumonia  is,  in  its  typical  form,  an 
oval  coccus,  with  one  end  smaller  and  more  tapering  than  the  other. 
It  may,  however,  be  regularly  oval,  or  spherical.  It  is  1//  to  1.5//  in 
length,  and  one-half  or  one-third  as  broad.  Forms  occur  in  which 
the  width  is  only  one-half  or  one-fifth  of  the  length.  It  is  thus  really 
a  bacillus,  and  is  called  such  by  many  observers.  Two  cocci  are 
usually  found  together,  end  to  end,  hence  the  term  diplococcus;  and 
often  two  or  three  such  pairs  are  arranged  together  to  form  a  chain. 
These  chains  are  at  times  not  distinguishable  from  some  varieties  of 
streptococci,  and  there  may  be  a  close  connection  between  them.  The 
lanceolate  cocci  have  a  capsule,  a  fact  which  aids  in  the  diagnosis  of 
this  bacterium  more  than  the  pair  arrangement  or  lance-shape  (see 
Plate  III.,  Fig.  2). 

Pneumococci  are  stained  in  cover-glass  preparations  with  the  ordinary 
aniline  dyes,  as  given  above.  The  capsule  may  be  stained  and  differ- 
entiated in  the  same  way,  but  it  more  often  requires  a  special  method. 
Welch  recommends  the  following  :  Spread  and  dried  cover-glass  prep- 
arations are  treated  first  with  glacial  acetic  acid,  which  is  allowed  to 
drain  off,  and  is  replaced  (without  washing  in  water)  with  aniline  oil- 
gentian- violet  solution.  (See  under  Tubercle  Bacilli.)  The  staining 
solution  is  repeatedly  added  to  the  surface  of  the  cover-glass  until  all 
of  the  acid  is  displaced.  The  specimen  is  now  washed  in  a  weak  salt 
solution  (about  2  percent.),  and  examined  in  the  same,  not  in  balsam. 
The  capsule  and  coccus  can  then  be  differentiated.  Degenerative  and 
involution  forms  are  constantly  met  with.  There  will  be  variations  in 
size  and  shape,  and  the  capsule  may  contain  only  remains  of  a  coccus, 
or  be  entirely  empty. 

Biological  Properties.  The  micrococcus  lanceolatus  is  not  motile, 
and  never  forms  spores.  It  is  facultative  anaerobic.  It  grows  in 
various  alkaline  media.  Favorable  temperature  35°  to  37°,  death- 
point  57°  C.  The  growth  is  very  rapid  in  liquid  media,  rendering  the 
fluid  cloudy  in 'six  to  twelve  hours.  After  about  forty-eight  hours  the 
multiplication  stops  and  the  micro-organisms  settle,  leaving  the  fluid 
clear.  In  gelatin  stab-cultures  small  white  colonies  form  along  the 
puncture.  It  does  not  liquefy  the  gelatin.  On  agar  it  forms  very 
characteristic  jelly-like  drops. 

By  inoculation  into  susceptible  animals  a  typical  fibrinous  pneumonia 
is  developed.  The  pathogenic  power  attenuates  rapidly  in  cultures,  but 
recovers  its  virulence  by  passing  through  susceptible  animals. 

This  micro-organism  is  found  in  all  cases  of  croupous  pneumonia. 
It  is  also  found  in  health  in  the  saliva,  and  in  empyemas  due  to  its 
presence,  making  a  favorable  prognosis,  in  meningitis,  epidemic  cere- 
brospinal meningitis,  ulcerative  endocarditis,  acute  abscesses,  otitis 
media,  and  certain  forms  of  arthritis. 

Bacillus  of  Influenza.     This  micro  organism  is  found  in  purulent 


PLATE    III. 

Fig.  i. 


81v. 


Pneumococci  from  a  Case  of  Empyema. 
(Oc.  4,  ob.  '/is  immersion.)    Drawn  by  J.  D.  Z.  Chase. 


FIG.  2. 


A 


i 


A*  ^ 


f    *&    u 


"*$*.. 


fi> 


Tubercle-bacilli  1  red ) .     Streptococci  (blue  chains). 
(Oc.  4,  ob.  Vm  oil  immersion.)    Drawn  by  J.  D.Z.Chase. 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  293 

sputum.  It  was  first  detected  by  Pfeiffer.  The  bacilli  have  the  form 
of  minute  rods,  single  or  in  chains  of  three  and  four,  and  stain  well 
in  Loffler's  methylene-blue  fluid  and  in  the  dilute  Ziehl-Neelsen  fluid. 
Cultivations  have  been  made  on  glycerin -agar.  When  solidified  ob- 
liquely, separate  colonies  form,  which  after  twenty-four  hours  appear 
like  drops  of  water,  visible  only  with  a  lens.  In  the  blood  they  can 
be  detected  in  cover-glass  preparations  after  staining.  After  keeping 
the  dried  cover-glass  preparation  in  an  absolute  alcohol  bath  for  five 
minutes,  stain  from  three  to  six  hours  in  eosin-methylene-blue  fluid  (see 
formula). 

Actinomyces.  When  the  lungs  or  pleura  are  infected  by  this  fungus 
actinomyces  will  be  found  in  the  sputum.  The  disease  in  these  organs 
is  rare.  Macroscopically  they  appear  as  small  kernels,  yellowish-white 
or  greenish-yellow,  and  having  the  shape  of  a  millet-seed.  Under  the 
microscope  they  are  recognized  by  the  rounded,  club-like  bodies  project- 
ing from  all  sides  of  an  unformed  central  mass.  They  are  seen  better 
when  not  stained. 

Chemistry  of  Sputum.  As  the  chemical  examination  of  the 
sputum  does  not  aid  us  in  diagnosis,  it  has  but  little  or  no  value. 
Mucin,  nuclein,  and  serum-albumin  are  constituents  of  sputa  in  health. 
Peptone  is  present  whenever  there  is  pus,  and  is  specially  marked  in 
pneumonia.  Volatile  fatty  acids,  such  as  butyric  and  acetic,  occur  at 
times,  markedly  so  in  pulmonary  gangrene.  Glycogen  has  been  ob- 
tained by  Solomon,  and  a  ferment  resembling  one  of  the  pancreatic 
ferments  has  been  detected,  especially  in  pulmonary  gangrene  and 
putrid  bronchitis.  Of  inorganic  substances,  chlorides  of  soda  and 
magnesia;  phosphates  of  soda,  lime,  and  magnesia;  sulphates  of  soda 
and  lime;  carbonate  of  soda,  lime,  and  magnesia;  and  in  a  few  cases 
phosphate  of  iron  and  silicates  have  been  obtained.     (Von  Jaksch.) 

The  Data  Obtained  by  Inquiry. 

The  Subjective  Symptoms.  Dyspncea.  Dyspnoea,  in  its  true 
sense,  means  difficult  breathing.  The  respirations  are  deeper  than 
natural,  but  of  normal  frequency,  or  they  may  only  be  more  frequent 
than  they  should  be,  or  they  may  be  both  deeper  and  more  frequent. 
The  patient  is  usually  conscious  of  suffering  or  of  some  distress  in 
breathing.  Lung  disease  without  dyspnoea  :  While  a  common,  indeed 
almost  constant  symptom  of  lung  disease,  it  does  not  follow  that  because 
a  patient  has  extensive  disease  of  the  lung  he  need  suffer  from  difficult 
or  hurried  breathing.  This  is  because  the  system  requires  no  more  air 
than  the  capacity  of  the  lung  is  able  to  supply.  The  change  takes 
place  very  gradually,  but  many  persons  with  chronic  fibroid  phthisis, 
or  with  emphysema,  in  both  of  which  the  disease  may  be  extensive, 
may  not  have  dyspnoea,  unless  an  unusual  demand  is  made  upon  the 
system.  The  subjects  are  under-weight,  move  slowly,  and  otherwise 
show  that  they  are  deprived  of  an  essential  to  active  being. 

Variety  of  Dyspncea  depending,  upon  Cause. 

I.  Anything  which  cuts  off  or  lessens  the  normal  amount  of  air 
required  for  oxygenation  of  the   blood       A.  Obstruction  of  the  air- 


294  SPECIAL  DIAGNOSIS. 

passages.  B.  Diminution  of  air-space  from  causes  within  and  outside 
of  the  thorax.  C.  Interference  with  the  action  of  the  muscles  con- 
cerned in  breathing. 

II.  Affections  which  lessen  the  amount  of  blood,  as  obstructive 
heart  disease.     Rarely,  tumors  pressing  upon  the  bloodvessels. 

III.  Affections  in  which  the  red  blood-corpuscles  are  diminished — 
anaemia. 

IV.  Pulmonary  embolism  and  thrombosis.  In  cases  of  weak  heart 
the  vessels  become  occluded.  After  labor  a  clot  of  blood  may  escape 
from  a  uterine  sinus,  be  carried  to  the  right  heart,  and  thence  to  the 
pulmonic  veins.  The  clot  may  arise  from  inflammation  of  the  veins 
in  any  situation. 

V.  Fat-embolism.  Foreign  substances  in  the  blood,  as  fat,  occur- 
ring in  parturient  women  three  or  four  days  after  labor,  after  fractures, 
and  in  diabetes. 

"VI.  Dyspnoea  due  to  interference  with  the  nervous  mechanism  of 
respiration,  a.  Tumor,  hemorrhage,  or  degeneration  about  the  respira- 
tory centre  in  the  medulla,  b.  Irritation  of  the  centre  by  toxic  agents, 
as  in  urseinia,  diabetes,  auto-intoxication  from  gastro-intestinal  disorder. 
To  this  class  belongs  "  heat  dyspnoea,"  which  occurs  in  all  febrile  con- 
ditions. The  warm  blood  acts  as  a  direct  irritant  to  the  respiratory 
centre  in  the  medulla  oblongata  (Landois).  This  explains  the  dyspnoea 
of  fever  and  the  curious  fact  pointed  out  by  Cohnheim,  that  the  respi- 
rations in  pneumouia  lessen  as  soon  as  the  fever  disappears,  notwith- 
standing the  persistence  of  the  physical  condition,  which  might  have 
accounted  for  the  dyspnoea.  Reflex  dyspnoea  (asthma,  q.  v.)  belongs 
to  this  variety.     The  dyspnoea  of  hysteria  is  of  the  same  class. 

Anything  which  cuts  off'  or  lessens  the  normal  amount  of  air  required 
for  oxygenation  of  the  blood.     A.   Obstruction  of  the  air-passages. 

1.  Occlusion  of  the  nares,  unless  compensated  by  niouth-breathing. 

2.  Enlargement  of  the  tonsils,  retro-pharyngeal  abscess,  or  any 
obstruction  in  the  throat,  from  diphtheritic  or  cedematous  swelling. 

3.  Disease  of  the  larynx,  causing  stenosis,  also  causes  a  character- 
istic form  of  dyspnoea  known  as  inspiratory  dyspnoea  (see  Disease  of 
the  Larynx). 

4.  Obstruction  of  the  trachea  or  bronchus  from  external  pressure  or 
from  a  foreign  body.  Dyspnoea  from  the  latter  cause  must  be  distin- 
guished from  dyspnoea  the  origin  of  which  is  higher  up  in  the  air- 
passages.  Inspection  of  the  upper  cavities  usually  reveals  the  cause. 
a.  Tracheal  Obstruction.  In  dyspnoea  from  occlusion  of  a  bronchus 
or  the  trachea  there  is  no  increase  in  the  movement  of  the  larynx. 
There  is  no  change  in  the  voice,  except  that  it  may  be  weakened,  and 
the  sonorous  quality  diminished.  If,  however,  there  is  at  the  same 
time  attendant  disease  of  the  larynx  from  syphilis,  or  paralysis  of  the 
muscles  from  pressure  on  the  recurrent  laryngeal  nerves  by  the  same 
cause  which  produces  the  tracheal  stenosis,  the  voice  will  be  modified. 
If  so,  on  laryngoscopy  examination  the  tumor  pressing  upon  the  larynx 
can  be  seen  at  times,  especially  if  the  larynx  is  healthy.  Expert 
operators  can  secure  quite  an  extensive  view  of  the  windpipe,  particu- 
larly if  the  head  is  bent  slightly  forward,  and  the  patient  is  seated  in 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  295 

the  upright  posture.  A  mirror  must  then  be  placed  against  the  soft 
palate,  with  the  surface  more  horizontal  than  usual.  By  this  means 
an  aneurism  may  be  seen  bulging  into  the  trachea.  It  must  not  be 
mistaken  for  pulsation  of  the  lower  end  of  the  trachea,  due  to  trans- 
mission of  the  impulse  of  the  aorta  to  the  trachea,  which  has  been 
shown  to  occur  in  healthy  persons. 

The  dyspnoea  is  expiratory  and  is  never  so  extreme  as  in  laryngeal 
stenosis.  The  lower  ribs  are  therefore  not  sucked  in  during  inspira- 
tion until  late  in  the  disease.  A  stridor  attends  the  dyspnoea  which  is 
heard  with  the  stethoscope  over  the  trachea,  as  well  as  over  every  part  of 
the  chest.  Sometimes  a  point  over  the  trachea  can  be  determined  at  which 
the  sound  is  heard  loudest.  The  point  may  indicate  the  seat  of  a  stenosis. 
Sometimes  the  sound  is  more  marked  over  the  larynx  than  over  the  ster- 
num, when  the  lower  part  of  the  trachea  is  obstructed.  Demme  has 
pointed  out  that  in  cases  of  prolonged  obstruction  in  the  lower  air-pas- 
sages the  upper  portion  of  the  thorax  may  diminish  in  size.  Not  only 
is  the  dyspnoea  constant,  but  paroxysms  may  take  place  in  which  the 
distress  is  very  severe.  These  paroxysms  of  dyspnoea  may  be  due  to 
spasm  of  the  vocal  cords;  but  it  is  very  likely  that  they  are  due,  as 
Bristowe  has  shown,  to  swelling  of  the  mucous  membrane,  or  to  mucus 
which  has  accumulated  at  the  point  of  obstruction  and  cannot  be  dis- 
lodged, or  to  spasm  of  the  muscular  tissue  of  the  trachea  itself.  In 
addition  to  the  subjective  symptom  of  want  of  breath  the  patient  may 
complain  of  pain  or  oppression  behind  the  sternum,  or  possibly  only  of 
a  slight  soreness.  Cough  usually  attends  the  dyspnoea,  with  expectora- 
tion of  mucus.  Sometimes  the  mucus  is  blood-tinged,  and  even  streaks 
of  blood  may  be  expectorated  after  a  considerable  time,  in  cases  of 
leaking  aneurism. 

If  the  obstruction  is  due  to  a  foreign  body,  the  dyspnoea  is  of  the 
same  type,  but  occurs  suddenly. 

b.  Bronchial  Obstruction.  If  a  bronchus  is  obstructed,  the  lung  to 
which  air  passes  freely  becomes  the  seat  of  extensive  emphysema. 
When  obstruction  takes  place  gradually,  compensatory  emphysema 
occurs,  developing  slowly,  not  rapidly  as  in  the  former  instance,  the 
degree  depending  upon  the  amount  of  obstruction  in  the  opposite  bron- 
chus. When  the  bronchus  is  obstructed  the  physical  signs  are  pro- 
nounced. The  vesicular  murmur  over  the  corresponding  side  of  the 
chest  is  absent,  fremitus  is  absent,  the  movement  of  the  affected  side 
is  impaired.  With  these  changes  the  percussion-sound  is  normal.  As 
the  case  advances,  the  affected  side  may  fall  in  and  measure  less  than 
the  opposite  side.  A  snoring  or  whistling  sound  may  be  heard  over  the 
root  of  the  lung,  between  the  scapula  and  vertebra?,  or  moist  rales  may 
be  present. 

The  causes  of  tracheal  and  bronchial  obstruction  are:  first,  tumor 
of  the  thyroid  (/land;  second,  thoracic  aneurism;  third,  mediastinal 
tumor  from  other  causes  than  aneurism,  as  disease  of  the  glands, 
cancerous  or  tubercular,  or  mediastinal  abscess;  fifth,  cancer  of  the 
oesophagus ;  and,  finally,  in  rare  cases,  a  dilated  auricle.  Bu1  diseases 
of  the  walls  of  the  trachea  also  cause  obstruction  by  narrowing 
the  calibre.     Syphilis   is   the  most  frequent  cause    of  such    obstruo- 


296  SPECIAL  DIAGNOSIS. 

tion.  Within  the  lumen  the  presence  of  a  foreign  body  causes 
obstruction.  The  foreign  body  may  remain  free  for  a  time,  moving 
up  and  down  as  the  patient  coughs,  and,  indeed,  it  may  be  felt  against 
the  side  of  the  trachea  when  the  finger  is  placed  outside  the  neck. 
Later  the  foreign  body  usually  becomes  fixed  in  the  right  bronchus,  or 
one  of  its  main  divisions,  because  the  opening  of  the  right  bronchus 
is  more  direct  than  that  of  the  left.  In  some  instances  the  body  may 
be  dislodged  and  fall  into  the  opposite  bronchus.  Rarely  it  falls  first 
into  the  left. 

B.  Dyspnoea  from  Diminution  of  the  Air-space  in  the  Lungs.  All 
forms  of  pulmonary  disease  attended  by  consolidation,  by  compression 
of  the  lung,  or  occlusion  of  the  small  bronchi,  are  included  under  this 
subdivision.  The  degree  of  dyspnoea  of  course  depends  upon  the 
extent  of  the  diminution  in  the  air-space.  In  pleural  effusions  from 
any  cause  the  air-space  is  lessened  and  dyspnoea  occurs.  In  bilateral 
effusions  it  is  more  marked  than  in  unilateral.  The  severity  of  the 
dyspnoea  depends  somewhat  upon  the  rapidity  with  which  the  effusion 
takes  place.  In  cases  of  sudden  effusion  of  air,  as  in  pneumothorax,  the 
dyspnoea  is  very  alarming  at  first,  but,  as  accommodation  takes  place, 
it  is  gradually  relieved.      In  rapid  effusion  of  serum  it  is  also  serious. 

The  characteristic  form  of  dyspnoea  due  to  lessened  air-escape  is  seen 
when  obstruction  of  the  air-tubes  takes  place  on  account  of  spasm. 
The  attack  comes  on  suddenly  in  the  midst  of  quiet  breathing  (see 
Asthma).  It  occurs  in  paroxysms  in  asthmatic  subjects.  It  may 
occur,  however,  on  slight  exertion,  or  it  may  in  a  measure  be  constant. 
But  when  the  dyspnoea  that  is  associated  with  asthma  is  constant,  other 
changes  have  taken  place  in  the  lungs.  First,  there  is  persistent  bron- 
chitis; second,  the  presence  of  emphysema.  Indeed,  in  many  cases  it 
is  difficult  to  ascertain  the  exact  sequence  of  affections.  In  emphy- 
sema of  the  lungs  dyspnoea  is  constant,  but,  on  exposure  to  cold  or  on 
account  of  an  attack  of  indigestion,  more  severe  paroxysms  may  occur, 
as  well  as  asthmatic  attacks,  although  the  patient  is  not  an  asthmatic. 
On  the  other  hand,  a  patient  may  have  had  asthma  for  a  number  of 
years,  during  which  attacks  of  dyspnoea  occurred  only  in  paroxysms. 
As  time  passes  the  paroxysms  become  more  and  more  frequent,  and 
emphysema  develops.  With  the  advent  of  the  emphysema  the  dysp- 
noea becomes  more  constant. 

Asthma  is  a  type  of  dyspnoea  of  nervous  origin.  It  has  just  been 
said  that  it  is  due  to  spasm  of  the  bronchial  tubes.  This  may  occur 
from  a  number  of  causes  :  (a)  It  may  be  of  central  origin,  from  irri- 
tation of  the  pneumogastric  centre;  (6)  it  is  just  possible  that  some 
disturbance  of  the  trunk  of  the  pneumogastric  nerve  will  also-  cause 
asthmatic  dyspnoea;  but  what  concerns  us  most  is  (c)  the  paroxysmal 
dyspnoea  which  arises  reflexly  from  irritation  of  the  terminal  endings 
of  the  pneumogastric  nerve,  or  of  nerves  intimately  associated  with  the 
pneumogastric,  in  the  medulla.  (1)  Disease  in  the  upper  air-passages, 
as  polyps,  or  a  hypertrophy  of  the  turbinated  bones,  or  adenoid  growths, 
are  the  most  frequent  source  of  paroxysmal  dyspnoea.  Not  only  in 
permanent  disease  of  this  character  do  we  have  such  dyspnoea,  but 
temporary  irritants  applied  to  the  nares  likewise  produce  it.     Various 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  297 

odors,  the  irritation  of  micro-organisms,  or  of  pollen,  or  emanations 
from  vegetable  life,  provoke  attacks  of  nasal  congestion  and  reflex 
dyspnoea.  The  irritation  is  propagated  through  the  ethmoidal  and 
posterior  nasal  branches  of  the  nerve,  the  Vidian  and  naso-palatine 
nerves,  to  the  septum,  and  the  anterior  palatine  to  the  middle  and 
lower  turbinates.  (2)  Irritation  in  the  fauces  and  larynx  is  not  so 
likely  to  cause  dyspnoea,  yet  there  is  no  doubt  that  the  presence  of  a 
constant  irritant  in  these  situations  tends  to  provoke,  or  keep  in  a  state 
of  excitability,  the  respiratory  tract,  so  that  asthma  is  more  likely  to 
persist. 

(3)  To  this  class  of  cases  belongs  the  irritation  of  the  terminal 
branches  of  the  pneumogastric  nerve  in  the  stomach.  Peptic 
asthma,  or  the  asthma  of  indigestion,  may  owe  its  origin  to  these 
causes.  Often  the  irritation  is  central,  due  to  the  irritating  influence 
of  an  abnormal  product  of  indigestion  upon  the  respiratory  centres  in 
the  medulla.  (4)  For  the  same  reason  we  have  asthma  due  to  other 
poisonous  substances  circulating  in  the  blood,  as  the  poison  of  uraemia. 
The  dyspnoea  due  to  this  condition  usually  occurs  in  paroxysms,  but 
may  become  constant.  Sometimes  it  is  the  first  intimation  of  the  pres- 
ence of  renal  disease.  The  dyspnoea  of  diabetic  coma  may  occur  from 
the  same  cause.  The  nature  of  both  is  recognized  more  particularly  by 
their  associate  symptoms.  The  condition  of  the  urine,  the  odor  of  the 
breath,  and  the  exhalations,  the  presence  of  hypertrophy  of  the  heart 
and  of  an  accentuated  second  sound,  point  to  a  urasmic  origin.  The 
history  and  symptoms  of  diabetes,  the  odor  of  acetone  on  the  breath, 
the  presence  of  sugar  in  the  urine,  the  absence  of  organic  pulmonary 
disease,  point  to  diabetes.  The  dyspnoea  of  uraemia  cannot  be  distin- 
guished from  other  forms  of  dyspnoea,  except  by  the  exclusion  of  car- 
diac and  lung  disease.  It  is  often  difficult  to  do  this,  because  uraemia 
so  frequently  develops  after  the  hypertrophied  heart  has  failed,  so  that 
the  physical  signs  of  dilatation  may  be  sufficient  to  explain  the  dyspnoea. 
The  dyspnoea  of  diabetic  coma,  known  as  "  air-hunger,"  is  character- 
ized by  slow  and  deep  respirations.  Cheyne-Stokes  respiration  is  due 
to  the  same  cause,  namely,  irritation  in  the  medulla,  as  in  other  forms 
of  nervous  dyspnoea.  It  must  not  be  forgotten  that  the  dyspnoea  of 
uraemia  may  present  the  Cheyne-Stokes  phenomenon. 

Diminution  of  Air-space  from  Extra-pulmonary  Causes.  Anything 
which  crowds  upon  the  thorax,  interfering  with  pulmonary  expansion, 
causes  dyspnoea.  This  is  notably  the  case  in  affections  below  the  dia- 
phragm. Hence  in  enlargements  of  the  various  organs  of  the  abdo- 
men, as  the  liver,  spleen,  kidneys,  pancreas  (cystic  disease),  and  uterus, 
dyspnoea  always  occurs.  In  accumulations  of  gas  (flatulency),- or  of 
fluid  (ascites),  the  diaphragm  is  pressed  upward  and  encroaches  <>n  the 
thoracic  capacity.  In  abdominal  tumor,  as  of  the  ovary,  the  omentum, 
and  of  the  organs  above  mentioned,  dyspnoea  is  a  distressing  feature. 

C  Interference  with  the  Action  of  the  3fuscles.  Practically  any  de- 
rangement of  the  action  of  the  respiratory  muscles  diminishes  the  air- 
space, as  expansion  of  the  lungs  is  interfered  with.  Nevertheless  the 
cause  of  the  dyspnoea  is  extra-pulmonary.  It  is  due  to  weakness  or 
paralysis  of  the  muscles  concerned  in   breathing,  or  to  inhibition  of 


298  SPECIAL  DIAGNOSIS. 

their  action  on  account  of  pain,  or  to  interference  with  their  action  on 
account  of  obesity,  myxcedema,  or  oedema,  or  on  account  of  actual  dis- 
ease, as  in  trichinosis  or  myositis. 

1.  Phrenic  dyspnoea  is  a  peculiar  form  due  to  paresis  of  the  phrenic 
nerve  and  consequently  to  interference  with  the  action  of  the  diaphragm. 
It  may  not  be  observed  as  long  as  the  patient  is  at  rest.  Upon  slight 
exertion  the  effort  distresses  him  and  causes  an  increase  in  frequency 
of  the  respirations.  After  a  few  steps  a  sense  of  suffocation  ensues, 
or  upon  ascending  an  elevation  the  patient  must  stop  frequently  to  take 
breath. 

Other  physiological  processes  are  affected  in  phrenic  dyspnoea.  In 
the  act  of  sighing  the  patient  feels  as  though  the  abdominal  organs 
were  drawn  up  into  the  chest.  Any  straining  effort,  as  defalcation,  is 
rendered  difficult.  The  voice  is  weak,  and  there  is  difficulty  in  cough- 
ing and  sneezing,  because  a  full  inspiration  cannot  be  taken.  A  slight 
attack  of  bronchitis  may  be  very  serious  on  this  account.  On  inspec- 
tion during  inspiration,  instead  of  the  natural  expansion  of  the  ribs 
and  chest,  the  epigastrium  and  the  hypochondriac  regions  are  drawn  in. 
During  expiration  they  are  pushed  forward.  The  thoracic  movements 
are  reversed.  The  abnormality  may  be  detected  on  palpation  with 
both  hands  below  the  cartilages  of  the  ribs,  even  better  than  by  inspec- 
tion. Unilateral  paralysis  of  the  diaphragm  causes  drawing  in  of  the 
corresponding  hypochondriac  region. 

In  progressive  muscular  atrophy,  in  general  lead-poisoning,  and  in 
multiple  neuritis  from  other  causes,  paralysis  of  the  diaphragm  may 
take  place.  It  is  said  to  occur  in  hysteria,  and  Walshe  states  that  he 
has  seen  it  after  diphtheria.  In  fatty  degeneration  of  the  diaphragm, 
on  account  of  inflammation  extending  from  the  peritoneum  to  the  pleura, 
the  same  phenomenon  has  been  seen.     It  may  occur  in  trichinosis. 

Paralysis  of  the  diaphragm  must  be  distinguished  from  inaction. 
If  during  the  act  of  inspiration  one  or  both  hypochondriac  regions  are 
drawn  in,  it  is  diagnostic  of  inaction  rather  than  of  paralysis;  whereas 
paralysis  of  the  diaphragm  is  always  accompanied  by  paralysis  of  other 
muscles. 

Dyspnoea  due  to  paralysis  of  other  respiratory  muscles  can  be  recog- 
nized on  careful  inspection  and  palpation.  The  atrophied  groups  of 
muscles  are  readily  observed.     Electricity  may  aid  in  the  diagnosis. 

2.  Pain  inhibits  muscular  action.  The  source  of  the  pain  may  be 
in  the  pleura,  the  muscles,  or  the  intercostal  nerves.  Frequently  it  is 
below  the  diaphragm,  as  in  peritonitis,  hepatitis,  etc.,  interfering  with 
the  action  of  that  muscle.  The  dyspnoea  that  occurs  from  pain,  as 
pleuritis,  or  inflammation  of  the  chest-wall,  is  recognized  by  the  posture 
which  is  taken  in  order  to  relieve  the  affected  side,  by  local  tenderness, 
and  by  the  physical  signs  of  pleurisy  or  of  pleurodynia. 

Clinical  Varieties.  We  observe  whether  dyspnoea  is  (a)  influenced  by 
exertion,  (6)  attended  by  alteration  in  the  respiratory  rhythm,  (c)  con- 
stant or  paroxysmal. 

(a)  Influenced  by  Exertion.  1.  Shortness  of  breath  may  be  apparent 
on  exertion  only,  as  in  cases  of  simple  debility,  or  of  interference  with 
respiratory  action  on  account  of  obesity.      It  is  the  form  of  shortness 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  299 

of  breath  seen  in  anaemia  and  in  moderate  cardiac  debility.  It  may 
not  be  observed  by  the  patient  unless  he  walks  hurriedly  or  ascends  a 
flight  of  stairs.  2.  Shortness  of  breath  independent  of  exertion  is  of 
more  serious  import,  and  is  due  to  a  number  of  causes.  It  is  the 
shortness  of  breath  that  is  seen  in  severe  cardiac  and  pulmonary  disease. 
To  the  latter  belong  asthma  and  emphysema,  bronchial  obstruction, 
pulmonary  consolidation  and  compressions  (by  effusions). 

(b)  The  Bate  of  Respiration.  Dyspnoea  varies  clinically,  depending 
upon  the  frequency  of  the  respiration.  In  its  most  extreme  form  it  is 
known  as  orthopncea,  when  the  upright  posture  of  the  trunk  is  assumed. 
(See  Posture.) 

1.  Dyspnoea  with  respiration  slow  or  normal,  a.  Dyspnoea  may  be 
characterized  by  deep  inspirations,  the  frequency  of  respiration  being 
less  than  normal.  This  is  one  of  the  forms  of  dyspnoea  seen  in  diabetic 
coma — "  breathlessness  without  dyspnoea."  It  is  most  characteristic, 
and  associated  with  nausea,  vomiting,  and  coma,  while  the  breath  and 
urine  smell  of  acetone,  b.  The  breathing  may  be  slow  and  stertorous. 
Such  breathing  is  likewise  associated  with  coma,  but  the  coma  is  of 
central  origin,  due  chiefly  to  apoplexy  or  tumor.  It  may  be  observed 
that  slow  respirations  with  dyspnoea  are  usually  central  or  toxic. 
Toward  the  end  of  life  the  respirations,  even  though  hurried  before, 
become  slower  from  carbon  dioxide  intoxication. 

2.  Irregvlar  respiration.  Alternately  slower  and  shallower  breath- 
ing, and  then  quicker  as  well  as  deeper,  is  seen  in  the.  peculiar 
form  of  breathing  known  as  Cheyne-Stokes  respiration.  It  includes 
a  period  of  apnoea,  with  simultaneous  alterations  in  the  size  of  the 
pupils.  (See  Uraemia  and  Diseases  of  the  Brain.)  3.  Respirations 
increased.  The  respirations  may  be  hurried  and  create  distress  in 
simple  nervousness  alone,  and  hurried  respiration  is  quite  common  in 
cases  of  hysteria.  In  the  latter  affection  the  frequent  breathing  is 
often  attended  by  distress.  The  respirations  are  quickened,  and  are 
half  the  normal  pul^e-rate  or  even  as  frequent  as  the  pulse.  The  term 
"panting"  is  applied  to  such  respiration.  The  same  character  of 
breathing  is  seen  in  exophthalmic  goitre.  _  The  rate  of  respiration  is 
increased  in  all  forms  of  dyspnoea  upon  exertion  (see  above),  and  in 
all  forms  due  to  heart  or  lung  disease. 

(c)  Dyspnoea  may  be  further  divided  clinically  into  constant  and  par- 
oxysmal dyspnoea.  Constant  dyspnoea  implies  a  persistence  of  the 
cause.  Paroxysmal  dyspnoea  does  not  include  the  form  that  is  increased 
by  exertion — a  form  which  in  one  sense  may  be  paroxysmal.  It  is  seen 
in  its  most  typical  form  in  asthma.  It  is  often  of  cardiac  origin,  but 
may  be  due  to  central  or  reflex  causes.  It  occurs  usually  at  night;  <  !on- 
stant  dyspnoea  is  frequently  subject  to  aggravations  paroxysmal  in  occur- 
rence.    Asthma  is  the  type  of  true  paroxysmal  dyspnoea. 

Diagnosis.  While  dyspnoea  is  usually  easy  of  recognition,  it  must 
not  be  forgotten  that  attacks  of  acute  indigestion,  with  thoracic  symp- 
toms of  oppression,  may  simulate  the  oppression  of  dyspnoea.  This 
form  of  dyspnoea  is  temporary,  however,  and  not  associated  with 
increased  rapidity  of  respiration.  Dyspnoea  is  recognized  by  increase 
in  rapidity  of  chest- movement,  with  increased  action  of  all  the  muscles 


300  SPECIAL  DIAGNOSIS. 

of  respiration,  both  the  essential  and  the  auxiliary  muscles.  At  the 
same  time  the  expression  is  pronounced.  The  alse  nasi  move,  the 
eyes  and  countenance  are  indicative  of  more  or  less  agony,  the  pupils 
are  dilated.  As  the  dyspnoea  continues  cyanosis  develops,  and  fre- 
quently a  cold  sweat  breaks  out.  This  may  be  limited  to  the  forehead 
and  face  and  to  the  extremities,  or  may  become  general.  The  hands 
and  feet  become  cold.  Stupor  sets  in,  carpo-pedal  spasm  or  general 
convulsions  follow,  the  respirations  become  slower,  and  death  takes 
place  in  coma  or  from  heart-failure  (asystole). 

The  dyspnoea  of  emphysema  is  characteristic;  it  is  due  to  inability 
to  empty  the  chest  of  air  (expiratory  dyspaoea).  The  inspiration  is 
short  and  quick;  the  expiration  is  prolonged,  and  all  the  auxiliary  mus- 
cles are  called  upon  to  complete  the  act.  The  powerful  abdominal 
muscles  are  seen  to  contract  vigorously,  and  thus  aid  in  pressing  up 
the  diaphragm.  The  quaclratus  lumborum  and  serratus  posticus  supe- 
rior et  inferior  draw  down  the  ribs.  The  scaleni  are  strongly  con- 
tracted, the  serratus  magnus,  latissimus  dorsi,  and  the  pectorales  all 
aid  in  elevating  the  ribs.  Knowledge  of  the  processes  involved  in 
forced  expiration  renders  the  diagnosis  comparatively  easy.  The  con- 
traction of  the  broad  abdominal  muscles  confirms  the  diagnosis. 

Cough  in  Pulmoxaey  Affections.  (See  Larynx.)  Coughing 
is  a  reflex  act.  A  deep  inspiration  is  taken,  followed  by  closure  of  the 
glottis,  succeeeded  immediately  by  a  sudden  expiratory  effort  during 
which  the  glottis  is  opened,  causing  a  loud  sound  with  the  forcible  pas- 
sage of  air  outward,  along  with  any  substances  in  the  air-vessels. 
The  pulmonic  irritation,  on  account  of  which  the  act  takes  place, 
usually  begins  in  the  respiratory  mucous  membrane.  The  cough  is 
then  used  to  expel  accumulations  of  mucus  or  pus,  or  foreign  sub- 
stance. It  occurs  in  all  forms  of  bronchitis  and  in  the  lung  affections 
generally  in  which  bronchitis  is  associated.  The  cough  of  phthisis, 
if  not  laryngeal,  is  due  to  a  localized  bronchial  catarrh.  Nodules  out- 
side of  the  bronchi,  situated  in  the  lung  substauce,  do  not  provoke  the 
act  of  coughing,  as  we  see  in  the  the  calcareous  and  fibrous  nodules  of 
healed  tuberculosis.  The  irritation  is  not  limited  to  the  mucous  mem- 
brane of  the  bronchial  tubes,  but  occurs  iu  the  mucous  membrane  of 
any  portion  of  the  respiratory  tract.  A  foreign  body  of  any  kind  in 
the  bronchus  sets  up  cough.  It  is  notably  present  in  pharyngeal  and 
laryngeal  diseases.  The  cough  of  the  latter  is  of  peculiar  character, 
which  renders  it  easily  distinguished  from  cough  due  to  other  causes. 
Cough  may  also  occur  from  causes  outside  of  the  air-passages.  It 
may  be  of  centric  origin.  Kohts  has  found  by  experiment  that  irrita- 
tion of  the  floor  of  the  fourth  ventricle,  above  the  centre  for  respira- 
tion, excites  a  cough.  This  centric  origin  may  possibly  explain  the 
cough  of  hysteria,  and  the  short,  barking  cough  which  arises  in  hys- 
terical or  nervous  states,  when  the  patient  is  afflicted  with  the  idea  that 
he  is  about  to  have  hydrophobia.  Irritation  of  nerves  which  are  in 
anatomical  relation  with  the  pneumogastric  also  excites  cough. 

Ear-cough.  The  most  characteristic  cough  of  this  form  is  that  due 
to  the  presence  of  a  foreign  body  in  the  meatus  of  the  ear,  or  to  disease 
of  that  organ.    It  is  sometimes  difficult  to  examine  the  external  auditory 


DISEASES  OF  THE  LUNGS  AND  PLEUEJE.  301 

meatus,  because  coughing  is  excited.  The  afferent  nerve  which  receives 
the  irritation  is  the  auriculotemporal  branch  of  the  fifth  nerve,  accord- 
ing to  Dr.  Fox,  and  not  the  minute  auricular  twig  of  the  vagus. 

Tooth-cough.  The  same  authority  points  out  the  occurrence  of  cough 
from  the  irritation  of  the  stump  of  a  tooth,  and  refers  to  cough  in  infants 
during  the  first  dentition. 

Stomach-cough.  The  popular  opinion  that  cough  is  very  frequently 
due  to  the  stomach  is  not  substantiated  by  the  experiments  of  Kohts. 
Nevertheless,  we  frequently  observe  cough  in  patients  who  are  suffer- 
ing from  mild  gastric  catarrh,  the  treatment  of  which  relieves  the 
cough.  This  is  in  all  probability  due  to  the  fact  that  with  the  gastritis 
there  is  a  secondary  pharyngitis,  and,  as  the  former  is  relieved,  the 
latter,  which  causes  the  cough,  disappears  entirely. 

It  will  be  seen,  therefore,  that  when  investigating  the  cause  of  a 
cough  in  diseases  in  which  this  symptom  is  prominent,  it  is  necessary 
not  only  to  make  examination  of  the  respiratory  tract  throughout  its 
course,  but  also  to  examine  the  condition  of  the  ears  and  the  teeth, 
and  to  bear  in  mind  its  possible  centric  origin. 

Clinical  Characteristics.  The  cough  may  be  dry  or  moist.  1.  A 
dry  cough  occurs  when  there  is  an  irremovable  source  of  irritation  (see 
dry  cough  of  laryngeal  disease).  It  is  seen  in  the  first  stage  of  bron- 
chitis. It  occurs  in  the  earlier  stages  of  phthisis.  As  a  short,  hacking, 
suppressed  cough  it  occurs  in  pleurisy  in  the  first  stage.  In  the  second 
stage  it  is  superficial,  as  if  the  sound-waves  were  checked.  It  is  char- 
acteristic and  most  familiar,  although  described  with  difficulty.  It  is 
the  best  type  of  cough  due  to  irritation  outside  of  the  respiratory  tract. 
The  ear-cough  and  tooth-cough  partake  of  this  character.  In  cases  of 
emphysema  the  cough  may  be  dry  and  unproductive  for  a  long  time, 
and  only  be  relieved  after  a  small  pellet  of  tough  mucus  is  discharged. 
In  the  same  category  belong  the  nervous  cough,  which  is  nothing  but 
a  bad  habit;  the  cough  of  hysteria,  and  the  cough  of  a  peculiar  bark- 
ing character  that  occurs  at  puberty,  which  Sir  Andrew  Clark  has 
described. 

2.  The  moist  cough  is  attended  by  expectoration  of  a  mucus,  muco- 
purulent, purulent,  or  bloody  character,  which  is  comparatively  easily 
removed.  Dry  and  moist  or  loose  cough  may  be  either  constant  or 
paroxysmal,  or  both.  The  moist  cough  may  occur  in  paroxysms  only, 
each  paroxysm  being  relieved  by  the  removal  of  the  irritation,  the 
subsequent  paroxysm  not  taking  place  until  the  irritating  secretion  has 
reaccumulated.  In  cases  of  bronchitis  of  the  second  stage  paroxysms 
of  cough  may  occur  every  few  hours,  or  the  cough  may  take  place  once 
in  the  twenty-four  hours,  usually  in  the  morning  on  arising.  The 
accumulated  secretions  of  the  night  are  disposed  of,  and  then  the 
patient  remains  free  from  annoyance.  Under  some  circumstances  the 
cough  is  almost  constant.  The  irritation  is  constantly  present.  A 
large  amount  of  secretion  is  rapidly  poured  out,  keeping  up  a  constant 
cou^h.  This  is  seen  in  bronchorrlura  and  bronchial  dilatation  and  in 
the  later  stages  of  tuberculosis.  In  these  affections  the  moist  cough 
may  occur  three  or  four  times  in  twenty-four  hours,  during  which  time 
an  enormous  amount  of  sputum  is  thrown  off.      The  cavity  is  thereby 


302  SPECIAL  DIAGNOSIS. 

emptied,  the  accumulation  of  matter  in  which  excites  coughing  only 
after  a  certain  level  is  reached.  In  this  affection  the  cough  is  further 
characterized  by  aggravation  on  change  of  position.  In  pertussis  the 
character  of  the  cough  is  of  special  diagnostic  significance;  it  occurs 
in  paroxysms.  The  expiratory  efforts  are  frequent  and  rapid,  followed 
by  a  noisy,  prolonged  inspiration,  during  which  the  characteristic 
whoop  is  created.  At  the  same  time  the  appearance  of  the  counte- 
nance is  marked.  The  face  is  cyanosed,  the  eyes  stare,  the  appearance 
of  distress  is  most  striking.  The  labored  efforts  at  coughing  frequently 
terminate  in  an  attack  of  retching  or  vomiting. 

It  must  not  be  forgotten  that  the  presence  of  an  irritant  does  not 
always  excite  cough.  Thus,  .when  the  sensibilities  are  obtunded,  as  in 
typhoid  fever,  in  disease  of  the  brain,  or  in  the  last  stages  of  any  dis- 
ease, the  presence  of  mucus  will  not  excite  cough,  and  yet  it  is  known 
to  be  in  the  trachea,  on  account  of  the  rattling  which  takes  place.  In 
cases  of  phthisis  sudden  checking  of  the  cough  and  expectoration,  on 
account  of  weakness,  is  of  bad  prognosis  and  denotes  approaching  death. 
It  is  also  a  bad  sign  in  pneumonia. 

The  Sound.  The  character  of  the  sound  is  usually  modified  by  the 
condition  of  the  larynx,  for  which  consult  the  section  on  Laryngeal 
Diseases. 

The  diagnostic  significance  of  cough  is  estimated  by  the  character; 
by  the  sound;  whether  constant  or  paroxysmal;  by  the  frequency  of 
the  paroxysm;  by  its  development  at  particular  times  or  under  partic- 
ular circumstances,  as  on  rising  in  the  morning,  or  change  to  a  cold 
atmosphere,  or  speaking,  or  upon  movement,  as  in  phthisis.  By  the 
sound,  laryngeal  and  bronchial,  coughs  are  distinguished.  Constant 
cough  implies  a  persistence  of  the  cause,  which  is  strictly  pulmonary, 
as  in  pleurisy,  phthisis,  bronchitis,  and  consolidations  generally;  par- 
oxysmal, a  recurrence  of  cause  when  pulmonary,  or  a  reflex  or  central 
cause.  Paroxysmal  coughs  occur  in  cases  of  cavities,  either  of  the  lung 
or  of  the  pleura  opening  into  the  lung.  Cough  is  excited  whenever 
the  cavity  fills  with  secretion.  The  paroxysm  may  occur  daily  or  sev- 
eral times  a  day.  Paroxysmal  cough  occurs  in  bronchitis  after  a  certain 
amount  of  secretion  accumulates.  It  is  the  cough  of  irritation  outside 
of  the  lung,  excited  by  reflex  influences.  The  association  with  retch- 
ing and  vomiting  is  of  some  diagnostic  significance.  It  is  seen  not 
only  in  whooping-cough,  but  also  in  phthisis.  The  diagnostic  value 
of  cough  further  depends  on  a  knowledge  of  its  duration  and  the  char- 
acter of  the  expectoration.     (See  Sputum.) 

Hemorrhage.  Hemorrhage  of  the  lungs  occurs  from  disease  or 
from  rupture  of  adjacent  bloodvessels  into  the  air-passages.  It  is  not 
in  itself  a  symptom  of  lung  disease.  A  hemorrhage  may  be  small  in 
amount  and  continue  over  a  considerable  period  of  time,  or  it  may  be 
characterized  by  a  sudden  profuse  discharge,  which  at  once  terminates 
the  life  of  the  patient. 

Cause.  A.  Affections  of  the  lungs.  1.  Anything  which  causes 
congestion  of  the  lungs  will  lead  to  hemorrhage.  The  amount  of  blood 
is  small;  it  may  be  limited  to  streaking  of  the  expectoration,  or  a  few 
mouth  fuls  may  be  discharged.     In  (a)  organic  heart  disease  this  form 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  303 

of  hemorrhage  is  seen.  It  is  also  a  characteristic  feature  of  the  first 
stage  of  (6)  croupus  pneumonia.  The  rusty-colored  sputum  is  due  to 
the  rupture  of  the  capillaries.  In  (c)  hemorrhagic  infarcts  hemorrhage 
occurs,  and  is  diagnostic  if  attended  by  the  sudden  formation  of  a  con- 
solidated area  in  the  lung.      In  (d)  phthisis  it  also  occurs  (see  below). 

2.  Tuberculosis.  In  tuberculosis  hemorrhage  may  occur  either  (1) 
as  the  first  symptom  of  the  disease,  on  account  of  collateral  congestion 
around  infiltrated  areas,  or  (2)  later,  on  account  of  ulceration  of  an 
artery  when  excavation  of  the  lung  has  taken  place.  In  the  early 
stages  the  hemorrhage  is  usually  profuse,  but  not  fatal.  It  may  occur 
repeatedly  during  a  series  of  weeks,  excited,  no  doubt,  by  the  violent 
non-productive  cough  which  attends  the  earlier  stages  of  this  disease. 
In  the  later  stages,  when  the  vessels  are  ulcerated,  the  patient  may 
have  repeated  hemorrhages,  varying  from  a  few  ounces  to  half  a  pint 
or  a  pint.  They  may  occur  daily,  or  be  repeated  at  intervals  of  a  week 
or  more  for  a  long  period  of  time.  After  the  hemorrhages  that  occur 
at  long  intervals  the  patient  experiences  much  relief.  Indeed,  the 
dyspnoea,  cough,  and  chest  oppression  subside  in  a  remarkable  degree, 
and  the  occurrence  of  another  hemorrhage  is  often  predicted  by  a  grad- 
ual recurrence  of  these  symptoms.  Death  does  not  usually  ensue  on 
account  of  the  large  hemorrhage  from  phthisical  ulceration,  and  yet  it 
may  possibly  take  place.  The  writer  has  seen  four  instances  of  hem- 
orrhage into  a  large  cavity,  three  with  external  hemorrhage,  which 
caused  death  instantly.  3.  Hemorrhage  recurring  frequently  is  sig- 
nificant of  cancer  of  the  lungs,  in  the  absence  of  other  causes.  4.  It 
is  of  common  occurrence  in  plastic  bronchitis,  when  large  bronchial 
casts  are  expelled.  5.  In  gangrene  of  the  lung  it  frequently  occurs, 
often  causing  death.  The  odor  and  sputum  indicate  the  true  nature  of 
the  primary  lesion.  6.  Hemorrhage  with  the  expectoration  of  calca- 
reous masses  occurs  and  recurs  frequently  in  patients  with  healed  or 
quiescent  tubercle. 

B.  Disease  outside  of  the  respiratory  tract.  (1)  Aneurismal  disease 
of  the  bloodvessels  which  are  in  intimate  relation  with  the  trachea  and 
bronchus  frequently  causes  ulceration  into  these  tubes,  with  hemor- 
rhage. The  hemorrhage  is  usually  profuse  and  often  induces  sudden 
death.  Sometimes  the  profuse .  hemorrhage  may  be  preceded  for  days 
by  small  hemorrhages.  The  physical  signs  of  aneurism  are  sufficient 
to  explain  the  cause.  The  bleeding  can  sometimes  be  seen  in  the  tra- 
chea, when  an  aneurism  of  the  innominate  artery  or  the  aorta  presses 
upon  that  tube.  (2)  In  diseases  of  the  heart  it  does  not  usually  take 
place  until  the  later  stages  of  the  disease,  and  is  associated  with  sec- 
ondary congestion  of  the  lungs.  It  may,  however,  be  an  early  symp- 
tom in  mitral  stenosis.  The  hemorrhages  may  amount  only  to  staining 
of  the  sputum,  or  several  times  during  the  day  an  ounce  or  more  of 
blood  may  be  expectorated. 

C.  Affections  of  the  blood  or  bloodvessels,  with  hemorrhages  in  other 
portions  of  the  body.  Thus,  it  may  occur  in  haemophilia,  in  purpura, 
in  scurvy,  and  in  anaemia.  It  occurs  in  jaundice  with  hemorrhages 
in  other  situations. 

D.  Gouty  endarteritis.     In  the  aged  of  both  sexes,  hemorrhages  take 


304  SPECIAL  DIAGNOSIS. 

place  independently  of  disease  of  the  heart  or  of  the  parenchyma  of 
the  lungs.  Sir  Andrew  Clark  and  others  have  spoken  of  these  hemor- 
rhages and  attributed  them  to  gouty  changes  in  the  vessels  as  well  as 
to  degenerations  of  lung-tissue,  on  account  of  which  the  rupture  took 
place. 

E.  Without  known  cause.  In  certain  instances  pulmonary  hemor- 
rhages occur  in  which  it  is  quite  difficult  to  find  any  cause  for  the  dis- 
charge. It  is  quite  common  to  see  hemorrhage  occur  in  females:  some- 
times at  the  menopause,  in  other  cases  during  menstruation,  or,  again, 
perhaps  vicariously,  when  menstruation  does  not  occur.  A  number  of 
cases  that  have  come  under  the  writer's  observation  have  had  this  ten- 
dency for  years  without  the  development  of  pulmonary  disease,  and, 
apparently,  without  much  influence  on  the  general  health.  Indeed,  it 
may  be  said  that  recurrent  hemorrhage  from  the  lungs  in  women,  in 
the  absence  of  organic  disease,  is  not  of  grave  significance. 

The  Symptoms.  The  only  symptom  may  be  the  presence  of  blood 
in  the  expectoration,  or  the  discharge  of  a  small  amount  of  blood  with 
slight  cough.  In  either  instance,  unless  the  patient's  mental  condition 
is  rendered  obtuse  by  disease,  the  hemorrhage  is  alarming  to  him.  He 
is  much  perturbed,  and  there  may  be  palpitation  of  the  heart,  besides 
other  nervous  phenomena.  Apart  from  the  nervousness  excited  by 
the  sight  of  blood,  small  hemorrhages,  and  even  hemorrhages  of  mod- 
erate amount,  do  not  cause  any  other  symptoms.  The  symptoms  of  a 
large  hemorrhage  depend  upon  the  amount  of  blood  that  is  lost.  They 
may  amount  to  faintness  and  giddiness  only,  with  or  without  pallor. 
If  more  pronounced,  syncope  may  take  place;  extreme  pallor  develops; 
the  pulse  becomes  rapid,  small,  and  feeble;  the  extremities  are  cold,  and 
the  face  bathed  in  perspiration.  If  the  patient  recovers  from  the  syn- 
cope, he  is  extremely  restless,  sighing  and  breathing  hurriedly.  There 
may  be  some  nausea.  Moderate  delirium  and  mild  febrile  symptoms 
often  follow  the  restlessness.  If  the  hemorrhages  do  not  recur  and  the 
patient' s  fears  are  calmed,  the  color  will  gradually  return  and  the  heart's 
action  become  stronger  and  slower.  These  symptoms  occur  whether 
the  hemorrhage  is  due  to  disease  of  the  lungs  or  to  aneurism  rupturing 
into  the  bronchus.  If  the  hemorrhages  are  large,  they  differ  somewhat 
in  the  two  conditions.  If  a  large  aneurism  ruptures,  the  blood  rap- 
idly wells  up  into  the  throat  and  pours  out  through  the  nostrils  and 
mouth  with  great  rapidity.  With  such  hemorrhage  the  end  may  come 
in  a  few  minutes.  In  pulmonary  hemorrhages  the  discharge  is  not  so 
profuse,  and  is  attended  by  coughing.  With  each  cough  blood  is 
raised  to  the  amount  of  a  tull  mouthful  at  a  time.  The  blood  dis- 
charged from  the  lungs  is  bright  in  color,  very  frothy,  being  mixed 
with  air.  There  are  no  clots  in  the  discharged  fluid.  The  blood 
from  an  aneurism  is  also  bright  red,  but  is- not  frothy,  unless  the  dis- 
charge is  very  slow,  and  becomes  mingled  with  air  in  the  vessels.  In 
rare  cases  of  pulmonary  hemorrhage  an  abundant  stream  pours  out, 
which  is  dark  in  color,  free  from  clots,  and  not  mixed  with  air  (large 
cavity). 

Diagnosis.     Hemorrhage  from  the  lungs  must  be  distinguished  from 
hemorrhage  from  the  upper  air-passages  and  from  the  stomach  and 


DISEASES  OF  THE  LUNGS  AND  PLEUR.E.  305 

oesophagus.  Thus  a  discharge  of  blood  from  the  mouth  may  occur 
from  cracks  in  the  pharynx,  or  varicose  veins.  It  is  not  abundant,  and 
the  hemorrhage  is  mingled  with  mucus,  which  is  streaked  with  blood. 
Hemorrhage  from  the  gums  may  be  taken  for  pulmonary  hemorrhage; 
but  if  there  is  no  stomatitis,  or  inflammation  of  the  gums  from  scor- 
butus or  ptyalism,  the  source  of  the  blood  can  easily  be  traced.  In 
stomatitis  its  color  is  somewhat  different.  It  is  thin,  fluid  blood,  often 
offensive,  of  cherry-juice  color.  Hemorrhage  from  the  lungs  is  dis- 
tinguished from  hemorrhage  from  the  stomach  by  the  difference  in  the 
way  in  which  it  is  discharged,  and  the  difference  in  the  character  of 
the  blood.  In  hemorrhage  from  the  stomach  the  blood  is  vomited. 
It  is  mixed  with  particles  of  food  or  oiher  gastric  coutents.  It  is  dark 
in  color,  often  of  the  appearance  of  coffee-grounds;  it  is  not  mixed 
with  air,  and  hence  is  not  frothy.  The  rapid  hemorrhage  from  ulcer- 
ation of  an  aneurism  into  the  oesophagus,  or  rupture  of  varicose  veins 
at  the  lower  end  of  the  oesophagus,  cannot  be  distinguished  from  the 
hemorrhage  that  occurs  when  the  aneurism  ruptures  into  a  bronchus. 
The  recognition  is  dependent  upon  the  physical  signs  and  the  previous 
history  of  the  patient's  illness. 

Pain.  Pain  is  rarely  a  symptom  of  disease  of  the  lungs  unless  the 
pleura  is  involved.  In  a  case  of  bronchitis  there  may  be  some  soreness 
and  oppression  behind  the  sternum,  but  otherwise  pain  is  absent.  In 
pleurisy  pain  occurs  before  the  exudation.  It  is  sharp  and  lanci- 
nating, and  so  severe  as  to  impede  respiration  and  cause  the  cough 
to  be  short  and  catchy.  It  is  usually  seated  at  the  base  of  the  chest, 
in  the  lateral  or  anterior  region.  It  occurs  when  the  patient  attempts 
to  take  a  full  breath.  Before  the  inspiratory  excursion  is  half  com- 
pleted it  is  checked  involuntarily  on  account  of  the  pain.  The  patient's 
hand  is  placed  upon  the  affected  part  and  he  involuntarily  leans  to  that 
side.  The  pain  of  pleurisy  may  be  increased  by  local  pressure,  but 
general  pressure,  as  from  the  whole  hand,  a  broad  bandage,  or  a  large 
strap  of  adhesive  plaster,  always  gives  relief.  In  the  pleurisy  that 
attends  phthisis  pain  is  quite  common.  It  is  of  the  same  character 
as  the  pain  of  acute  plastic  pleurisy,  but  varies  in  situation  and  in 
degree.  The  pain  occurs  in  paroxysms.  It  follows  a  slight  exposure 
to  cold,  undue  exertion,  or  fatigue.  It  may  continue  for  twenty-four 
hours,  and  disappear  till  a  repetition  of  the  cause  brings  it  on  again. 
It  must  be  distinguished  from  the  myalgia  of  phthisis  due  to  cough  and 
exposure.  In  myalgia  the  muscles  and  fascia?  at  the  bony  attachments 
are  very  tender. 

The  pain  of  pleurisy  must  be  distinguished  from  pleurodynia,  from 
intercostal  neuralgia,  and  from  the  pain  due  to  disease  of  the  ribs. 
In  jjleurodynia  the  muscles  are  sensitive  if  pressed  between  the  lingers 
or  palpated.  An  enlarged  area  is  affected,  but  physical  signs  of  pleu- 
risy or  pneumonia  cannot  be  elicited.  Cough  is  absent,  and  so,  usually, 
is  fever.  It  is  associated  with  pain  in  other  muscular  or  fibrous  struc- 
tures. There  may  be  a  previous  history  of  exposure  to  cold  and  damp- 
ness. Usually  there  is  a  history  of  lithsemia  or  frequent  myalgia. 
Intercostal  neuralgia  is  sometimes  difficult  to  distinguish.  The  pain 
is  sharp,    localized,   and    may  modify  the   movements  of   the   chest. 

20 


306  SPECIAL  DIAGNOSIS. 

General  pressure  relieves  it;  local  pressure  at  the  points  where  the 
terminal  filaments  of  the  nerve  come  to  the  surface  may  increase  it. 
The  so-called  Valleix's  tender  points  are,  however,  not  always  present 
in  cases  of  intercostal  neuralgia.  The  patient  is  usually  ansemic,  often 
the  subject  of  uterine  or  other  exhausting  disease,  and  may  suffer  from 
neuralgia  in  other  situations.  Cough  and  physical  signs  are  absent. 
Fracture  of  the  rib,  or  caries  of  the  rib,  may  be  recognized  by  the  local 
tenderness  and  by  the  signs  of  these  conditions.  Localized  pleurisy 
may  attend  both,  however — indicated  by  more  severe  pain  on  cough 
or  lull  breathing.  Caries  or  fracture  is  determined  by  pressure  upon 
the  diseased  rib,  which  elicits  the  crepitus  of  fracture.  An  empyema 
that  is  about  to  point  Avill  cause  pain  in  some  area  of  the  chest.  The 
pain  is  usually  seated  at  the  points  of  election  for  the  discharge  of  the 
empyema,  and  is  soon  followed  by  swelling,  with  heat  and  redness  of 
the  skin,  and  the  occurrence  of  oedema. 

More  or  less  constant  pain  at  the  apices,  undoubtedly  independent 
of  affections  of  the  muscles,  is  a  suspicious  sign  of  tuberculous  disease 
in  that  situation.     It  may  be  aggravated  by  pressure. 

Special  Diagnosis. 

Diseases  of  the  Bronchi.  Diseases  of  the  bronchi  are  distinguished 
from  other  diseases  of  the  lungs  chiefly  by  the  difference  in  the  physical 
signs.  Except  in  capillary  bronchitis,  the  general  and  subjective  symp- 
toms are  not  so  severe  as  in  other  affections. 

We  are  aided  in  the  recognition  of  bronchial  affections,  first,  by  the 
fact  that  they  are  bilateral;  second,  that  the  bases  are  usually  affected; 
third,  that  there  is  diminution  of  fremitus  determined  by  palpation; 
fourth,  that  there  is  absence  of  dulness  on  percussion;  fifth,  that  rales 
are  more  pronounced  in  proportion  to  other  physical  signs,  and  more 
general  than  in  other  lung  affections. 

Bronchitis. 

Bronchitis  is  an  inflammation  of  the  mucous  membrane  of  the  bron- 
chial tubes.  It  may  be  acute  or  chronic,  may  involve  any  part  of  the 
bronchial  tree,  the  large,  the  middle-sized,  or  the  most  minute  branches, 
and  may  be  primary,  or  occur  secondarily  to  some  general  disease,  or 
to  disease  of  the  heart  or  kidneys. 

1.  Acute  Bronchitis  occurs  most  frequently  by  extension  of  the 
catarrhal  inflammation  from  the  nose  and  throat;  but  in  some- persons 
it  develops  so  suddenly  that  it  appears  to  be  primary  in  the  tubes. 

When  the  larger  or  middle-sized  tubes  are  involved,  the  patient  com- 
plains of  soreness  or  rawness  underneath- the  sternum,  especially  at  its 
upper  part.  There  are  frequently  a  feeling  of  tickling  in  the  throat, 
and  a  sense  of  weight  or  oppression  on  the  chest.  Chest  pain  is  due 
to  myalgia  or  the  strain  upon  the  muscles  from  coughing.  The  cough 
is  at  first  hard  and  dry,  and  often  produces  pain  of  a  tearing  character 
in  the  muscles  of  the  chest  and  abdomen.  The  cough  is  apt  to  be  worse 
when  the  patient  first  lies  down,  and  again  on  rising,  especially  after  a 


DISEASES  OF  THE  LUNGS  AND  PLEURJS.  307 

night's  rest.  Fever  is  usually  slight  and  of  short  duration.  The  res- 
pirations are  accelerated,  but  not  markedly,  and  there  is  no  dyspnoea. 
The  expectoration  is  at  first  a  white,  frothy,  viscid  mucus,  subsequently 
becoming  more  abundant  and  muco-purulent. 

Physical  Signs.  In  uncomplicated  cases  there  are  no  changes  in  the 
physical  structure  of  the  lungs.  On  examination  of  the  chest  the 
percussion-note  is  found  to  be  clear;  the  respiratory  murmur  more 
roughened  and  harsher  than  normal,  but  not  broncho-vesicular  or  bron- 
chial; accompanying  breathing  there  are  heard  sibilant  and  sonorous 
rales,  and,  in  the  later  stages,  some  large  and  medium-sized  mucous  rales. 
The  rales  vary  in  position  from  time  to  time,  and  especially  after 
comrhine;.  Vocal  resonance  and  fremitus  are  unaltered.  A  fremitus 
may  be  produced  by  sonorous  rales. 

The  cough  and  expectoration  usually  last  for  some  time  after  fever 
has  subsided.  The  duration  of  the  disease  is  from  a  few  days  to  sev- 
eral weeks.  It  is  never  fatal  except  in  the  very  old  and  very  young, 
or  in  those  who  are  much  debilitated. 

The  diagnosis  of  acute  bronchitis  is  easily  made  by  noting  the  fact 
that  the  disease  runs  an  acute  course  marked  by  fever,  cough,  and 
expectoration;  and  that  the  physical  signs  are  negative  except  as  to 
roughening  of  the  respiratory  murmur  and  the  existence  of  bronchial 
rales,  heard  on  both  sides  of  the  chest. 

From  croupous  pneumonia  and  local  tuberculosis  of  the  lungs  it  is 
distinguished  by  the  absence  of  dulness  on  percussion,  bronchial  breath- 
ing, and  increase  of  vocal  resonance  and  fremitus;  by  the  absence,  in 
other  words,  of  the  ordinary  signs  of  consolidation.  From  pneumonia 
it  is  further  distinguished  by  the  milder  character  of  the  subjective 
symptoms  and  by  the  fact  that  in  bronchitis  the  physical  signs  are 
almost  always  bilateral,  in  pneumonia  generally  unilateral.  From 
tuberculosis  it  is  further  distinguished  by  the  slow  progress  of  the 
latter,  which  involves  the  apices  preferably,  whereas  bronchitis  is  more 
marked  at  the  bases;  and  by  the  occurrence,  sooner  or  later,  of  hectic 
fever  and  emaciation,  which  are  absent  in  bronchitis.  Doubt  will  exist 
only  at  first;  the  progress  of  the  case  will  in  time  make  everything 
clear.  Systematic  examination  of  the  sputum  is  an  important  diagnostic 
aid,  and  will  lead  to  the  differentiation  of  many  cases  of  bronchitis 
from  tuberculosis  and  from  pneumonia.  In  infants  and  children  espe- 
cially, bronchitis  is  at  times  so  rebellious  to  treatment  that  tuberculosis 
is  suspected. 

In  broncho-pneumonia  (catarrhal  pneumonia)  there  is  a  diffuse  bron- 
chitis associated  with  small  areas  of  pneumonic  consolidation.  .  It  is 
distinguished  by  having  graver  general  symptoms  and  by  the  presence 
of  small  areas  over  which  there  are  dulness  on  percussion  and  bronchial 
breathing,  associated  with  the  physical  signs  of  bronchitis  already 
described. 

Acute  miliary  tuberculosis  of  the  lungs  is  very  easily  mistaken  for 
bronchitis,  because  dulness,  if  present,  amounts  to  nothing  more  than 
tympanitic  dulness,  because  the  signs  are  diffused  through  both  Lungs, 
and  because  the  respiratory  murmur  is  fainter  than  normal,  but  only 
slightly  roughened.     Close  inspection  of   the  patient  will,  however, 


308  SPECIAL  DIAGNOSIS. 

make  it  evident  that  his  condition  is  worse  than  could  be  accounted  for 
by  bronchitis  alone.  The  fever  is  higher,  the  respirations  more  fre- 
quent, pallor,  with  a  dusky  or  faintly  cyanotic  hue  intermingled,  is 
common,  perspiration  is  more  pronounced.  A  primary  focus  or  a 
source  of  infection  may  be  discovered. 

Acute  bronchitis  may  be  mistaken  for  spasmodic  laryngitis  (croup). 
It  is  distinguished  by  the  fact  that  the  spasms  are  less  pronounced 
in  bronchitis,  and  there  is  fever  in  addition  to  the  physical  signs.  In 
bronchitis  the  breathing  is  rarely  so  stridulous  as  in  laryngeal  spasm. 

Whooping-cough  cannot  be  distinguished  positively  from  bronchitis 
before  the  characteristic  whoop  appears;  but  it  may  be  suspected  when 
the  child  has  been  exposed  to  contagion,  and  when  the  coryza  and  red- 
ness of  the  fauces  persist  in  spite  of  treatment. 

In  the  diagnosis  of  bronchitis  it  is  often  more  difficult  to  determine 
the  primary  cause  than  it  is  to  distinguish  it  from  other  pulmonary 
affections.  Yet  the  former  is  more  important;  it  must  be  borne  in 
mind  that  bronchitis  is  a  frequent  accompaniment  of  many  febrile  dis- 
eases, such  as  typhoid  fever,  measles,  and  whooping-cough;  of  diseases 
of  the  heart  and  kidneys,  and  of  septic  diseases  and  blood  disorders. 
The  primary  will  not  be  likely  to  be  mistaken  for  the  secondary  disor- 
der if  one  is  upon  his  guard  and  insists  upon  finding  a  cause  for  each 
case  that  presents  itself. 

Measles  can  usually  be  diagnosticated  from  the  first  by  the  coryza, 
but  especially  by  the  red  spots  upon  the  auterior  half-arches  of  the  soft 
palate,  which  appear  usually  several  days  before  the  eruption  upon  the 
body. 

Bronchitis  is  a  common  and  important  early  symptom  of  typhoid 
fever.  The  latter  disease  may  be  suspected  when  the  fever,  prostra- 
tion, and  headache  are  greater,  and,  especially  if  these  symptoms 
coexist  with  a  loose  condition  of  the  bowels,  chilliness,  and  occasional 
nose-bleed. 

2.  Capillary  Bronchitis,  or  Suffocative  Catarrh,  is 
bronchitis  of  the  smaller  tubes.  It  occurs  most  frequently  as  an 
extension  of  the  catarrhal  process  from  the  larger  tubes,  but  some- 
times seems  to  attack  the  smaller  tubes  from  the  beginning,  or  coinci- 
dently  with  the  larger  tubes.  Infants,  young  children,  and  the  aged 
are  most  liable  to  it.  It  begins  with  a  succession  of  chills  or  chilliness, 
followed  by  high  fever.  The  temperature  may  rise  to  104°.  The 
skin  is  hot,  the  face  flushed.  The  head  and  neck  and  the  upper  por- 
tion of  the  trunk  may  be  covered  with  perspiration.  The  pulse  rapidly 
increases  in  frequency. 

The  aspect  of  the  patient  from  the  first  shows  that  the  illness  is 
graver  than  ordinary  bronchitis.  The  face  expresses  anxiety,  and  in 
children  the  alse  nasi  dilate  in  respiration,  which  is  both  accelerated 
and  difficult  (dyspmoea).  The  respirations  may  be  as  many  as  60  or  80 
to  the  minute,  the  pulse  not  being  correspondingly  rapid.  Dyspncea  is 
more  or  less  constant,  but  becomes  urgent  in  paroxysms,  and  the 
patieut  may  have  to  be  propped  up  in  bed  to  enable  him  to  breathe 
(or'hopnoea).  It  is  expiratory :  inspiration  may  be  free  and  easy,  or 
difficult;  but  expiration  is  always  difficult  and  prolonged.      In  children 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  309 

the  pause  in  the  act  of  breathing  takes  place  at  the  end  of  inspiration, 
instead  of  expiration. 

Cough  is  more  frequent  and  violent  than  in  ordinary  bronchitis,  and 
the  expectoration  is  viscid  and  difficult  to  raise.  As  the  disease  pro- 
gresses, dyspnoea  becomes  more  intense,  and  signs  of  insufficient  aera- 
tion of  the  blood  make  their  appearance  (cyanosis).  The  lips  and 
finger-nails  become  bluish,  and  the  extremities  cool  and  clammy.  If 
the  patient  is  unable  to  expel  the  tenacious  secretions  from  his  bron- 
chial tubes,  the  further  progress  of  the  case  is  that  of  rapidly  develop- 
ing cyanosis;  the  breathing  continues  frequent,  but  is  shallow  and  more 
labored.  Children  often  have  convulsions,  followed  by  coma  and  death, 
while  old  persons  sink  into  coma  without  preceding  convulsions. 

On  the  other  hand,  if  the  case  is  favorable,  the  patient  keeps  up  his 
strength  and  is  able  to  cough  hard  and  expectorate,  consciousness  is 
unclouded,  and  cyanosis  does  not  become  marked. 

The  physical  signs  are  those  of  bronchitis  of  the  larger  and  smaller 
tubes;  sibilant  and  sonorous  rales,  if  present  at  first,  give  way  to  fine 
subcrepitant  and  crepitant  rales,  which  speedily  become  moist  and  very 
abundant.  As  in  ordinary  bronchitis,  the  bases  of  the  lungs  posteriorly 
are  the  parts  most  involved.  The  percussion-note  of  both  lungs  re- 
mains clear,  but  there  is  apt  to  be  increased  resistance.  The  fremitus 
may  be  lessened  in  some  areas,  increased  in  others.  If  an  area  of 
dulness  appears,  it  may  be  due  to  pneumonia  or  to  collapse  of  the  lung ; 
if  the  former,  there  is  usually  an  access  of  fever. 

The  sputum  contains  mucus,  pus,  occasionally  blood-cells,  granular 
matter,  and  sometimes  fibrinous  casts  of  the  tubes.  The  micro-organ- 
isms found  are  the  micrococcus  lanceolatus,  streptococcus  pyogenes,  and 
staphylococcus  aureus  et  albus.     Mixed  infections  are  usually  present. 

3.  Chronic  Broxchitis  occurs  most  frequently  in  middle  or  later 
life.  Its  special  feature  is  long  duration,  without  fever,  and  with  com- 
paratively little  impairment  of  the  general  health.  Cough  is  not  con- 
stant; there  are  periods  when  it  is  entirely  absent;  the  disease  then 
returns,  perhaps  with  increased  severity,  and  lingers  indefinitely. 
Chronic  bronchitis  in  its  milder  form  consists  in  what  is  often  called 
"  winter  cough."  It  attacks  especially  persons  past  middle  life,  who 
have  emphysema.  It  appears  with  the  cold  weather,  and  lasts  until 
the  following  summer.  The  cough  is  not  severe,  though  sometimes 
paroxysmal,  and  expectoration  is  scanty,  non-purulent,  and  may  be 
confined  to  the  morning.  Dyspnoea  is  not  marked  unless  there  is  con- 
sidnrable  emphysema.  Acute  exacerbations  occur  from  time  to  time, 
and  the  tendency  of  the  disease  is  to  become  worse  from  year  to  year. 
and  to  be  more  r.ontinuous,  even  persisting  all  summer. 

In  the  dry  catarrh,  or  catarrhe  sec  of  Laennec,  paroxysms  of  cough 
occur  on  the  slightest  provocation,  with  the  expectoration  of  small, 
hard  pellets,  or  without  any  expectoration.  The  patients  are  emphyse- 
matous. 

The  diagnosis  is  made  by  noting  the  long  duration  of  the  disease 
without  impairment  of  the  general  health,  its  relation  to  season,  and 
the  absence  of  physical  signs  of  involvement  of  lung  tissue. 

The  physical  signs  of  chronic  bronchitis  are  those  of  bronchitis  of 


310  SPECIAL  DIAGNOSIS. 

the  larger  and  middle-sized  tubes.  Large  moist  rales  are  more  or  less 
abundant,  depending  upon  the  degree  of  swelling  of  the  mucous  mem- 
brane, and  the  quantity  and  fluidity  of  the  secretions.  The  respiratory 
murmur  is  roughened  and  less  intense  than  normal. 

W.  Fox  says  that  in  chronic  bronchitis  there  is  commonly  hyper- 
resonance  from  coexisting  emphysema,  but  under  acute  exacerbations 
the  bases  may  be  dull  from  congestion  or  oedema.  Respiration  is  harsh, 
and  in  some  cases  of  senile  bronchitis  expiration  may  be  both  prolonged 
and  high  pitched,  when  other  signs  of  dilatation  of  bronchial  tubes 
are  absent.     The  percussion-note  is  clear. 

The  sputa  of  the  severe  forms  of  chronic  bronchitis  are  usually 
copious  and  muco-purulent,  the  latter  predominating.  They  vary  in 
color  from  yellowish-white  to  ashy,  greenish,  or  black  when  the  lnngs 
are  anthracotic  or  collapsed. 

The  subjective  symptoms  of  the  patient  consist,  in  ordinary  cases,  of 
a  moderate  amount  of  dyspnoea,  and  tightness  across  the  chest.  At 
the  onset  of  a  fresh  attack  the  symptoms  may  be  those  of  acute  bron- 
chitis. The  cough  is  paroxysmal,  somewhat  resembling  that  of  whoop- 
ing-cough, but  without  the  characteristic  whoop.  It  is  usually  severest 
on  lying  down  and  when  rising  in  the  morning. 

The  quantity  and  character  of  the  sputa  vary  more  than  in  acute 
bronchitis.  Sometimes  they  are  very  copious,  consisting  of  serum 
mixed  with  mucus,  constituting  bronchorrhcea.  More  commonly  they 
are  scanty,  glairy,  and  tenacious. 

Chronic  bronchitis  may  be  the  result  of  repeated  acute  attacks,  or, 
rarely,  of  only  one.  It  is  frequently  found  in  association  with  gout, 
chronic  heart  di-ease,  chronic  endarteritis,  Bright' s  disease,  emphysema, 
asthma,  and  chronic  alcoholism.  It  may  alternate  with  other  gouty 
affections,  as  articular  inflammation  or  eczema,  being  relieved  when 
the  other  manifestations  are  more  marked.  It  also  accompanies 
tuberculosis  of  the  lungs.  Climate  and  season  have  a  marked  in- 
fluence; the  disease  is  worse  in  damp,  cold  climates,  and  in  the  winter 
months. 

Chronic  bronchitis  can  be  diagnosticated  from  the  cough  of  aneurism, 
by  the  absence  of  the  stridulous  breathing  due  to  paralysis  of  one-half  of 
the  vocal  cords,  and  by  the  local  signs  of  a  tumor  of  the  vessel.  Other 
tumors  may  cause  cough  by  pressure,  and  the  possibility  of  their  exist- 
ence should,  therefore,  be  borne  in  mind. 

4.  Plastic  Bronchitis  is  a  form  of  bronchitis,  usually  chronic,  the 
characteristic  feature  of  which  is  the  expectoration  of  fibrinous  casts, 
which,  when  unravelled  under  water,  are  found  to  be  solid  casts  of 
the  smaller  bronchial  tubes.  The  casts  are  often  tree-like  in  shape, 
showing  that  a  bronchial  tube  and  its  smaller  subdivisions  have  been 
occluded  by  the  casts. 

Persons  of  all  ages  are  liable  to  it,  but  it  affects  males  about  twice 
as  often  as  females. 

The  subjective  symptoms  are  cough  and  dyspnoea;  haemoptysis 
occurs  in  about  one  third  of  the  cases  (Biermer).1     The  cough  occurs 

1  Virehow:  Handbuch  derspec.  Path.  u.  Ther.,  Bd.  v.  Abtta.  1. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  31 1 

in  paroxysms,  which  are  frequent  and  severe;  relief  follows  expecto- 
ration of  the  casts. 

Hemorrhage  may  appear  only  as  streaks  of  blood  upon  the  casts,  or 
may  be  considerable,  and  follow  their  dislodgment.  The  casts  them- 
selves when  ejected  are  usually  coated  with  mucus,  so  that  they  appear 
as  solid  masses  of  sputum;  their  arrangement  into  cylinders  may  not 
be  suspected  until  they  are  agitated  in  water.  The  size  of  the  cylinder 
varies  from  that  of  the  little  finger  to  that  of  a  bodkin,  but  they  do 
not  often  exceed  the  size  of  a  goose-quill.  The  larger  casts  may  be 
hollow,  but  the  smaller  ones  are  solid,  and  are  arranged  in  layers. 
They  are  whitish  or  gray-  in  color,  and  firm  in  consistence,  but  become 
softer  as  the  disease  improves.  Microscopically,  the  casts  are  nearly 
structureless,  consisting  of  a  fibril lated  base,  with  pus  and  mucous 
corpuscles,  a  few  gland-cells,  and,  occasionally,  blood-cells  in  the  outer 
layers.     Charcot-Leyden  crystals  and  Curschmann's  spirals  are  found. 

The  acute  form  is  rare,  and  out  of  ten  cases  accepted  by  Biermer  six 
proved  fatal.  The  disease  begins  with  fever,  dyspnoea  appears  early, 
severe  paroxysms  of  cough  occur,  sometimes  hemorrhage.  Death  re- 
sults from  asphyxia.  Grave  symptoms  are  excessive  dyspnoea,  scanty 
expectoration,  and  drowsiness.  Copious  expectoration  is  a  favorable 
sign. 

The  duration  of  the  chronic  form  is  very  variable,  some  cases  lasting 
a  number  of  years;  but  is  not,  as  a  rule,  dangerous  to  life,  nor  does 
the  general  health  suffer  much. 

The  Physical  Signs.  The  casts  obstruct  the  bronchial  tubes.  There 
is  less  air  ^  entering  the  part,  hence  there  are  diminished  fremitus  and 
respiratory  murmur  over  the  portions  of  lung  supplied  by  the  obstructed 
tubes.  If  collapse  ensues,  there  is  dulness  on  percussion;  if  the  casts 
are  dislodged,  the  murmur  becomes  normal,  or  but  slightly  roughened. 
In  unaffected  portions  of  the  lung  resonance  is  clear  or  exaggerated, 
and  the  respiratory  murmur  remains  unaltered. 

Fuller  says  (quoted  by  Peacock  in  Diseases  of  Chest)  that  the  upper 
portions  of  the  lungs  are  oftener  affected  than  the  lower  portions. 

5.  Fcetid  or  Putrid  Bronchitis  is  the  name  applied  to  the  con- 
dition in  which  the  sputa  have  a  highly  offensive  odor  and  are  copious 
and  semi-putrid.  The  odor  is  said  by  some  to  be  due  to  microscopic 
sloughs,  and  by  others  to  a  special  bacillus. 

Putrid  bronchitis  may  accompany  (1)  dilatation  of  the  bronchial 
tubes;  (2)  chronic  pneumonia;  (3)  phthisis,  or  (4)  empyema  with  a 
fistulous  communication  with  a  bronchus;  or  (5)  it  may  occur  inde- 
pendently. The  subjective  symptoms  are  cough,  irregular  fever,  and 
occasional  chills.  The  physical  signs  are  those  of  chronic  bronchitis, 
or  of  bronchitis  and  the  conditions  with  which  it  may  be  associated 
(q.v.).  From  gangrene  it  is  diagnosticated  by  absence  of  physical  signs 
of  disintegration  of  lung  tissue  and  by  the  absence  from  the  sputum  of 
fragments  of  lung  tissue  and  elastic  fibres.  Nevertheless  gangrene  "I' 
the  lung  may  be  the  final  result  of  putrid  bronchitis. 

The  sputa  of  fcetid  bronchitis  have  an  odor  of  gangrene  or  feces. 
On  standing  theyseparate  into  three  layers.  The  upper  one  consists 
of  a  greenish,  fluid  or  frothy  layer;  the  second  is  sero-albuminous;  and 


312  SPECIAL  DIAGNOSIS. 

the  third  a  thick  granular  deposit  in  which  are  small  masses,  the  size 
of  peas  (Dittrich's  plugs),  and  flakes  consisting  of  granular  detritus 
and  containing  fat-crystals  and  bacteria,  the  o'idium  albicans,  and  crys- 
tals of  leucin  and  tyrosin.      (See  Sputum.) 

Specific  Bronchitis. 

In  addition  to  the  bronchitis  that  attends  the  infectious  disorders 
mentioned  above,  three  forms  are  seen  of  an  infectious  nature  which 
are  properly  classified  among  the  infectious  diseases.  It  is  proper  to 
refer  to  them  now,  as  bronchitis  is  usually  the  most  pronounced  local 
manifestation.  They  are  influenza,  whooping-cough,  and  hay-fever. 
The  last  only  will  be  spoken  of  at  present. 

Hay-fever. 

Hay-fever  is  a  specific  catarrh  of  the  respiratory  passages,  caused  by 
the  pollen  of  certain  plants,  principally  the  grasses.  The  attack  begins 
with  itching,  burning,  and  lacrymation  of  the  eyes,  and  pain  in  the 
brow  or  eyeballs.  Subsequently  there  is  itching  or  pricking  of  the 
nasal  mucous  membrane,  frequent  sneezing  and  an  irritating  watery 
discharge.  The  mucous  membrane  of  the  nose  is  red  and  swollen.  A 
similar  condition  obtains  in  the  throat  when  that  is  affected.  If  the 
disease  attacks  the  bronchial  mucous  membrane,  a  bronchitis  is  set  up, 
which,  if  it  differs  at  all  from  ordinary  bronchitis,  is  more  persistent 
and  attended  by  greater  dyspncea,  with  asthmatic  attacks. 

Bronchiectasis. 

Dilatation  of  the  bronchi  occurs  secondarily  to  affections  which  tend 
to  weaken  the  walls  of  the  tubes  and  to  lessen  their  elasticity.  Hence 
it  is  found  in  chronic  bronchitis  with  emphysema,  in  chronic  phthisis, 
in  catarrhal  pneumonia  in  children,  in  chronic  obstruction  from  external 
pressure  or  foreign  bodies  (see  Obstructions).  It  also  occurs  when  the 
lungs  contract  in  fibroid  pneumonia,  or  in  pleural  thickening.  It  occurs 
in  two  principal  forms  :  the  simple,  in  which  the  affected  tubes  are  uni- 
formly dilated;  and  the  saccular,  in  which  larger  or  smaller  pouches 
are  formed.  It  is  commoner  in  males  than  in  females,  and  probably 
begins  most  frequently  in  adult  or  middle  life.  One  lung  only  is  affected 
in  about  one-half  the  cases,  and  when  both  lungs  are  affected  (chronic 
bronchitis  and  emphysema)  it  is  not  often  to  the  same  degree. 

The  subjective  symptoms  consist  of  cough,  expectoration,  -and  a 
variable  amount  of  dyspnoea.  Eventually  there  may  be  some  loss  of 
flesh  and  strength. 

The  cough  is  usually  paroxysmal.  It  may  occur  only  in  the  morn- 
ing after  the  dilated  tube  fills.  It  may  follow  change  in  position.  A 
paroxysm  is  followed  by  copious  expectoration,  sometimes  amounting 
to  a  pint  and  a  half  in  twenty-four  hours.  It  is  grayish-brown  and 
muco-purulent,  faintly  or  extremely  foetid.  The  sputa  contain  mucus, 
pus,  casts  of  the  tubules,  and  various  salts.     Charcot-Leyden  and  fatty 


DISEASES  OE  THE  LUNGS  AND  PLEURA.  313 

crystals,  vibrios,  leptothrix,  and  bacteria  (Fox)  can  be  found  on  micro- 
scopic examination.  Elastic  fibres  are  found  only  if  the  tubes  are 
ulcerated.  In  a  conical  glass  the  sputum  separates  into  three  layers 
— a  frothy  brown  top,  a  thin  mucoid  layer  in  the  middle,  and  a  gran- 
ular layer  below.  Hemorrhage  is  rare,  but  may  occur  even  when 
tubercle  is  absent. 

Dyspnoea  is  not  usually  severe,  except  when  the  dilatation  is  com- 
plicated by  disease  of  the  heart  or  lungs,  or  during  an  acute  attack 
of  bronchitis. 

The  physical  signs  differ  according  to  the  extent  and  variety  of  the 
dilatation.  In  simple  dilatation  there  may  be  nothing  different  from 
the  signs  found  in  chronic  bronchitis,  except  a  tendency  to  more 
bronchial  respiration,  with  rales  having  a  metallic  quality.  Percussion 
will  vary  according  to  the  degree  of  alteration  of  the  lung  tissue  sur- 
rounding the  affected  bronchi,  and  according  to  the  extent  of  the  dila- 
tation and  its  proximity  to  the  surface.  In  the  simple  forms  the 
percussion -note,  if  altered,  is  somewhat  less  resonant  and  higher  in 
pitch,  whereas  in  saccular  dilatations,  favorably  situated  for  percussion, 
the  note  is  tympanitic  if  the  pouch  is  empty.  On  auscultation  in  sim- 
ple dilatation  the  breathing  approaches  the  bronchial,  and  is  accompa- 
nied by  bronchial  rales.  In  saccular  dilatation  the  sounds  are  practically 
those  of  a  cavity,  respiration  varying  from  bronchial  to  amphoric. 
Vocal  resonance  and  tactile  fremitus  are  usually  both  increased,  but 
the  latter  may  be  diminished. 

The  diagnosis  of  simple  dilatation  from  chronic  bronchitis  may  be 
impossible,  but  copious  and  foetid  expectoration  indicates  the  former. 
The  diagnosis  of  the  saccular  form  from  tuberculosis  of  the  lung  with 
cavity  is  difficult.  Wilson  Fox  says  the  severe  cases  are  usually  asso- 
ciated with  consolidation  of  the  lung  or  with  tubercle;  but  even  with- 
out the  presence  of  the  latter  they  often  present  phthisical  symptoms 
— retraction  of  the  chest,  with  the  physical  signs  of  excavation,  pains 
in  the  side,  haemoptysis,  pyrexia,  nocturnal  perspiration,  and  diarrhoea 
— which  may  all  coexist  with  only  an  induration  of  the  lung  and  dila- 
tation of  the  bronchi.  The  diagnosis  must  be  made  by  noting  the  per- 
sistency of  the  physical  signs,  which  change  but  little  and  are  not 
progressive  as  are  those  of  tuberculosis;  the  protracted  course  of  the 
disease;  the  character  of  the  sputum;  and  the  comparatively  slight 
impairment  of  the  general  health. 

Obstruction  of  the  Bronchi. 

Obstruction  may  be  produced  by  causes  external  to  the  tubes,  or  by 
internal  causes — i.  e.,  to  compression  or  to  constriction. 

Compression  may  be  by  tumor,  enlarged  glands,  aneurism,  hydatid 
cyst,  mediastinal  abscesses,  and  long-continued  pleural  effusions  and 
goitre. 

Constriction  may  be  produced  by  swellings  of  the  mucous  membrane, 
by  polypoid  growths,  or  by  growths  forming  in  the  lung  and  extending 
into  the  bronchi.  Cicatrices  may  be  produced  by  syphilis,  tubercle, 
or  by  pleural  thickenings. 


314  SPECIAL  DIAGNOSIS. 

The  symptoms  depend  upon  the  size  of  the  tube  and  the  degree  of 
stenosis.  When  small  areas  are  affected  there  may  be  no  demonstrable 
physical  signs,  because  the  lung  around  the  affected  area  becomes  emphy- 
sematous. When  large  areas  are  affected  percussion  often  continues 
resonant,  but  its  limits  are  said  to  be  less  influenced  by  forced  inspira- 
tion and  expiratiou  than  in  health.  The  breath-sounds  are  weakened, 
and  vocal  resonance  and  fremitus  are  diminished  in  intensity,  and  may 
be  absent.  Sibilant  and  sonorous  rales  may  be  heard  at  the  seat  of 
the  obstruction,  and  fremitus  may  be  felt  over  the  corresponding  area. 
Dyspnoea  is  in  proportion  to  the  stenosis  and  the  size  of  the  tube  occluded. 

Asthma. 

Asthma  is  a  chronic  disease  caused  by  spasmodic  narrowing  of  the 
bronchial  tubes,  and  characterized  by  paroxysmal  attacks  of  dyspncea, 
diminished  respiratory  movement  of  the  chest,  prolonged  expiration, 
attended  by  a  wheezing  sound  and  sibilant  rales,  and  ending  abruptly 
with  the  expectoration  of  tenacious  mucus.  The  attack  may  be  limited 
to  a  single  night,  or  may  be  prolonged  for  days,  with  nocturnal  exacer- 
bations. 

Premonitory  symptoms  are  said  to  occur  in  about  one-half  the  cases. 
These  are  for  the  most  part  nervous,  such  as  headache,  neuralgia,  irri- 
tability of  temper,  vertigo,  drowsiness.  Hyde  Salter  found  that  there 
were  premonitory  symptoms  in  111  out  of  226  cases  collected  by  him. 
In  63  they  were  nervous,  in  8  there  was  profuse  diuresis,  and  in  14 
they  were  connected  with  the  digestive  system. 

The  attack  itself  usually  begins  during  sleep,  and  often  at  a  regular 
time.  It  may,  however,  begin  during  the  day,  and  at  a  certain  hour, 
independently  of  sleep.  The  onset  is  manifested  by  tightness  across 
the  chest  and  more  or  less  difficulty  in  breathing.  This  dyspnoea 
increases  rapidly  and  often  reaches  an  extreme  degree.  The  face  be- 
comes pale  and  anxious,  and  may  be  covered  with  a  cold  perspiration; 
the  lips  are  dusky  from  insufficient  oxygenation  of  the  blood.  The 
patient  feels  smothered,  and  makes  frantic  efforts  to  get  his  breath, 
rushing  to  an  open  window,  no  matter  how  cold  the  weather,  or,  if 
unable  to  leave  the  bed,  sitting  up  with  the  hands  pressed  upon  the  bed 
so  as  to  give  purchase  to  the  accessory  muscles  of  respiration.  Not- 
withstanding that  great  respiratory  efforts  are  made,  the  chest  moves 
but  little,  because  the  lungs  are  already  distended  to  the  extent  of  a 
full  inspiration.  The  patient  is  unable  to  expel  the  contained  air  owing 
to  the  spasm  of  the  bronchial  tubes. 

The  frequency  of  respiration  is  diminished,  sometimes  to~one-half 
the  normal;  the  rhythm  is  also  altered,  inspiration  being  short  and 
gasping,  and  followed  without  pause  by  expiration,  which  is  much 
prolonged  and  accompanied  by  a  wheezing  sound  audible  to  bystanders. 

There  is  an  increased  amount  of  air  in  the  thorax,  and  inability  to 
remove  it.  The  chest  is  enlarged — barrel-shaped — the  movement  is 
lessened  and  strikingly  out  of  proportion  to  the  muscular  exertions. 
The  diaphragm  is  lowrered. 

The  physical  signs  are  hyper-resonance  on  percussion;  on  ausculta- 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  315 

tion,  faint,  short  inspiration,  prolonged  expiration,  and  sibilant  and 
sonorous  rales,  more  marked  on  expiration. 

The  duration  of  an  attack  of  asthma  varies  from  half  an  hour  to  a 
day  or  two.  In  patients  with  chronic  bronchitis  it  may  be  prolonged 
for  a  week  or  two,  with  remissions  during  the  day.  It  may  subside 
abruptly  or  by  degrees. 

Subsidence  of  an  attack  is  marked  by  expectoration,  the  sputa  hav- 
ing special  characteristics  (see  under  Sputum).  At  first  it  is  made  up 
of  rounded  gelatinous  masses  which,  when  unfolded  in  water,  are  seen 
to  be  made  up  of  spirals.     Later,  it  becomes  muco-purulent. 

No  duration  can  be  set  down  for  the  disease  itself.  It  may  be  said 
that  the  earlier  the  age  at  which  it  begins,  the  better  the  prospect 
of  ultimate  cure.  If  a  cause  can  be  discovered  and  its  operation 
avoided,  the  prospect  of  a  cure  is  better. 

The  causative  factors  in  asthma  are  various.  About  twice  as  many 
males  as  females  are  affected,  and  there  is  a  marked  hereditary  tendency 
in  some  families.  There  is  probably  some  special  peculiarity  in  asth- 
matic patients,  but  just  what  it  is  has  not  been  determined.  It  may 
reside  in  the  lungs,  and  may  be  part  of  a  general  constitutional  irrita- 
bility (Salter).  Bronchitis,  emphysema,  and  heart  disease  act  as 
causes,  and  so  do  syphilis,  malarial  poisoning,  and  chronic  Bright' s 
disease. 

Diseases  with  Increased  Amount  of  Air. 
Emphysema. 

Emphysema  consists  in  an  "  excessive,  permanent,  and  unnatural 
distention  of  the  air-cells,"  or  in  "  extravasation  of  air  into  the  inter- 
lobular or  subpleural  cellular  tissue."     (Laennec.) 

Emphysema  may  be  unilateral  or  bilateral.  Local  and  unilateral 
forms  are  usually  compensatory.  Bilateral  emphysema  may  be  hyper- 
trophic or  atrophic. 

It  is  more  common  in  men  than  in  women.  Its  symptoms  are  more 
common  in  childhood  and  after  middle  age.  Two  factors  are  essential 
in  its  causation.  First,  defective  development  of  the  elastic  tissue  of 
the  lungs.  Second,  increased  intra-alveolar  air-pressure.  The  latter 
is  due  to  a  number  of  causes.  In  childhood,  no  doubt,  nasal  and  naso- 
pharyngeal obstructions  are  operative.  In  adults  occupations  which 
necessitate  continuous  and  severe  muscular  effort,  especially  if  coupled 
with  forced  expiration  with  closed  glottis,  act  as  causes.  Such  occupa- 
tions are  blacksmithing  and  playing  upon  wind  instruments.  Diseases 
which  cause  much  coughing  or  respiratory  effort,  sudi  as  chronic  bron- 
chitis and  whooping-cough,  act  in  the  same  manner.  Chronic  mitral 
valvular  disease  and  the  lessened  elasticity  of  the  lung-tissue  of 
advancing  age  both  favor  congestion  of  the  lung,  and  thereby  pred im- 
pose to  emphysema.  The  disease  is  hereditary;  several  members  of 
a  family  are  affected.  It  occurs  in  many  in  childhood,  is  in  abeyance 
in  adult  life,  and  reappears  in  old  age. 

Symptom*.  The  prominent  symptoms  in  hypertrophic  emphysema 
are  dyspnoea,  cyanosis,  and  cough,  with  expectoration  Prom  associated 


316  SPECIAL  DIAGNOSIS. 

bronchitis.  There  is  no  fever.  The  dyspnoea  is  in  proportion  to  the 
degree  of  emphysema,  and  is  aggravated  by  the  coexistence  of  bron- 
chitis, asthma,  and  eccentric  hypertrophy  of  the  right  ventricle,  which 
are  very  frequent  complications  in  cases  of  long  standing.  When  the 
degree  of  emphysema  is  only  moderate,  dyspnoea  is  not  complained 
of  except  upon  climbing  or  walking  briskly,  or  after  a  hearty  meal. 
But  when  the  degree  of  emphysema  is  great,  dyspnoea  is  constant;  it 
interferes  with  all  exertion,  frequently  necessitates  orthopncea,  and 
prevents  continuous  speech,  so  that  patients  speak  in  broken  sentences 
or  syllables. 

Cyanosis  is  marked.  The  livid  lip  is  common  in  the  asylums  for 
old  men.  The  extremities  are  also  dusky,  and  the  blueness  is  general 
in  severe  cases.  This  cyanosis,  the  round  shoulders,  and  the  drawn, 
chronically  anxious  expression,  if  I  may  so  term  it,  make  it  easy  to 
pick  out  the  emphysematous  subjects  in  a  ward  of  chronic  cases. 

Respiration  is  not  accelerated,  and  may  be  diminished  in  frequency. 
It  is  often  accompanied  by  wheezing  when  chronic  bronchitis  coexists. 

The  cough  varies  greatly  in  frequency;  it  may  be  altogether  absent, 
since  its  presence  simply  indicates  an  associated  bronchits.  This  bron- 
chitis may  for  years  be  present  only  in  the  winter.  In  children  it 
may  be  associated  with  asthma.  It  may  arise  on  changes  of  the 
weather;  finally  it  becomes  chronic.  The  expectoration  is  that  of 
chronic  bronchitis  (q.  v.).     It  is  rarely  stained  with  blood. 

The  physical  signs  of  emphysema  depend  upon  its  degree,  and  upon 
whether  it  is  complicated  with  chronic  bronchitis  or  not.  Inspection  : 
In  well-marked  cases  the  chest  is  barrel-shaped  (see  under  Inspection). 
There  is  little  movement  of  the  chest  in  respiration,  because  the  lung 
is  already  in  a  condition  of  full  inspiration  (expiratory  dyspnoea). 
Vocal  fremitus'  and  resonance  are  usually  diminished.  Percussion  : 
The  percussion-note  is  abnormally  clear,  and  may  even  be  tympanitic. 
Hyper-resonance  is  typical  of  the  disease.  When  the  distention  is 
extreme  the  note  may  be  woodeny  (see  Fig.  38).  The  lungs  are  en- 
larged. The  heart-dulness  becomes  obliterated  by  the  overlapping  lung. 
The  upper  margin  of  the  liver  falls  one  or  two  interspaces  below  the 
normal.   The  resonance  extends  higher  above  the  clavicles  than  normal. 

On  auscultation  the  inspiration  is  found  to  be  distant  and  feebler  than 
normal,  while  the  expiration  is  prolonged,  and  may  become  three  or 
four  times  the  length  of  inspiration.  Grazing  or  rubbing  sounds  have 
been  described  and  attributed  to  the  friction  of  distended  vesicles  against 
the  pleura.  Other  adventitious  sounds  are  due  to  an  associated  bron- 
chitis, pleurisy,  or  tuberculosis.  But  bronchitis  is  such  a  common 
accompaniment  of  emphysema  that  the  rales  of  the  former  become 
almost  symptomatic  of  the  latter.  Their  character  in  emphysema 
does  not  differ  from  that  in  chronic  bronchitis  {q.  v.). 

The  Heart.  The  apex-beat  is  absent.  *  There  is  epigastric  pulsation 
or  systolic  shock.  The  normal  area  of  heart-dulness  is  encroached  upon 
by  the  distended  lung,  and  the  heart  itself  is  pushed  to  the  right,  the 
apex-beat  being  frequently  at  the  xiphoid  cartilage.  If  the  emphy- 
sema attain  a  very  high  degree,  there  may  be  no  perceptible  dulness, 
except  on  very  strong  percussion  over  the  cardiac  region.     The  heart- 


DISEASES  OF  THE  LUNGS  AND  PLEUIl.K.  317 

sounds  appear  feebler  and  more  distant  than  normal.  The  right  ven- 
tricle becomes  dilated  and  hypertrophiecl,  as  the  result  of  the  pulmonary 
congestion  produced  by  emphysema.  The  pulmonary  second  sound  is 
accentuated.  A  tricuspid  regurgitant  murmur  may  be  heard.  Venous 
congestions  are  common  in  the  later  stages.  Albuminuria  is  common. 
(Edema  of  the  feet  and  limbs  may  occur,  but  general  anasarca  is  rare. 

The  general  health  suffers  by  loss  of  strength  and  capacity  for  phy- 
sical and  mental  work,  rather  than  by  loss  of  flesh.  The  patients  are 
large-chested,  stoop-shouldered,  and  short-breathed,  and  have  an  anx- 
ious expression  of  countenance.  The  face  is  of  a  dingy  pale  color, 
but  becomes  bluish  on  exertion.  , 

Diagnosis.  This  is  based  upon  the  history  (heredity,  occupation, 
long  duration),  the  occurrence  of  dyspncea  and  cyanosis,  and  of  winter 
cough  or  chronic  bronchitis,  and  upon  the  physical  signs. 

Emphysema  can  be  distinguished  from  pleural  effusion  and  from  aneu- 
rism, which  may  cause  dyspnoea,  by  the  universal  hyper- resonance  on 
percussion.  Pleural  effusion,  which  also  causes  bulging,  is  usually 
unilateral,  and  the  percussion- note  is  flat.  The  area  of  dulness  of  the 
heart  and  aorta  is  diminished  in  emphysema. 

Pneumothorax,  which  most  resembles  emphysema  in  its  physical 
signs,  develops  suddenly,  affects  one  side,  and  has  a  hollow,  tympanitic 
note  on  percussion.  The  succussion- splash,  metallic  tinkling,  and  coin- 
test  have  no  counterpart  in  emphysema;  moreover,  the  antecedent 
history  and  mode  of  development  are  different. 

Atrophic  Emphysema  is  due  to  the  degeneration  of  age.  The 
lung  is  reduced  in  size.  The  diameters  of  the  chest  are  lessened.  The 
ribs  are  oblique.  There  is  atrophy  of  the  chest  muscles.  The  patients 
have  dyspnoea.     There  are  other  signs  of  senility. 

In  interlobular  emphysma  the  physical  signs  arc  the  same  as  those 
of  vesicular  emphysema,  but  it  develops  suddenly  and  is  liable  to  be 
followed  by  emphysema  (intercellular)  of  the  neck,  which  on  palpation 
gives  a  peculiar  crepitation.  The  friction-sound  and  crackling  which 
have  been  described  as  occasional  adventitious  sounds  in  vesicular  em- 
physema are  more  commonly  heard  in  the  interlobular  form. 

It  is  caused  by  rupture  of  the  air-cells,  and  hence  occurs  in  diseases 
in  which  a  great  strain  is  put  upon  them — especially,  therefore,  in 
whooping-cough,  but  also  occasionally  in  pulmonary  hemorrhage  and 
pneumonia;  violent  coughing  and  laughing,  and  great  straining,  as  in 
child-labor,  are  capable  of  producing  it. 

Diseases  with  Diminished  Amount  of  Air. — The  Consolidations. 

Congestion  of  the  Lungs. 

Active  Congestion.  In  active  congestion  there  is  increased  amount 
of  blood,  which  diminishes  the  air-space  by  encroachment  and  causes 
more  or  less  consolidation.  The  signs  of  that  physical  condition  are 
present — increased  fremitus,  impaired  resonance  or  dulness,  and  bron- 
chial breathing.  They  are  observed  on  both  sides,  usually  at  the  bases. 
Dyspncea,  cough,  and  frothy,  bloody  expectoration  attend  the  fluxion. 


318  SPECIAL  DIAGNOSIS. 

No  cases  have  yet  been  reported  in  -which  bacteriological  examination 
of  the  sputum  was  made.  Of  course,  the  micrococcus  lanceolatus  is  not 
found. 

If  the  above  signs  and  symptoms  develop  suddenly — within  twenty- 
four  hours — a  fluxion  to  the  lung  has  in  all  probability  taken  place. 
If  the  patient  is  subject  to  heart  disease,  or  if  he  has  been  exposed  to 
and  has  inhaled  hot  vapors  or  irritants,  the  probability  of  fluxion  is 
increased.  The  occurrence  of  fever  would  point  to  pneumonia  as  the 
cause  of  the  objective  and  subjective  symptoms. 

Passive  Coxgestiox.  The  physical  condition  that  results  is  con- 
solidation, manifesting  itself  by  slight  dulness  and  feeble  or  bronchial 
breathing;  the  bronchial  membrane  is  also  congested,  giving  rise  to 
abundant  rales.  The  affection  is  bilateral  and  usually  confined  to 
the  posterior  portions  of  the  bases.  It  is  also  secondary,  a.  Mechan- 
ical congestion  occurs  when  the  flow  of  blood  to  the  heart  is  obstructed, 
as  in  organic  valvular  disease  or  insufficiency.  Rarely  the  pressure  of 
tumors  on  the  pulmonary  veins  acts  in  a  similar  manner,  b.  Hypo- 
static congestion  occurs  in  fevers,  as  protracted  typhoid,  and  in  pro- 
longed general  exhaustion  or  adynamia.  Ascites  or  other  affections 
below  the  diaphragm,  which  lessen  the  respiratory  excursion,  cause 
this  form.  Dyspnoea,  cough,  and  expectoration  of  blood-stained  spu- 
tum are  common.  The  sputum  contains  alveolar  cells,  but  no  micro- 
organisms. 

CEdema.  The  air-cells  and  alveolar  walls  are  filled  with  serous 
exudation,  as  in  oedema  of  the  skin  It  is  frequently  due  to  the  weak- 
ness of  the  heart,  which  occurs  at  the  end  of  long-continued  diseases 
of  an  exhaustive  nature,  particularly  if  the  heart  is  overtaxed.  It 
occurs,  therefore,  in  the  terminal  stages  of  chronic  Bright' s  disease, 
of  organic  heart  disease,  of  the  anaemias  and  cachexias.  Both  conges- 
tion and  oedema  occur  in  cerebral  affections. 

Symptoms.  They  are  those  of  congestion  in  a  more  aggravated  form. 
Dyspnoea,  cough,  and  the  expectoration  of  large  quantities  of  a  sero- 
mucoid  fluid  are  seen  The  diagnosis  is  based  upon  the  result  of  phy- 
sical examination  and  the  history  of  the  above  causal  factors.  In 
cases  of  myocarditis  or  acute  dilatation  of  the  heart,  in  valvulitis 
with  failing  compensation,  oedema  of  the  lungs  often  takes  place  sud- 
denly. It  may  follow  some  unusual  exertion.  Its  onset  is  attended 
with  more  or  less  collapse,  increased  pulse-rate,  hurried,  oppressed,  noisy 
breathing,  cyanosis,  and  anxious  expression.  The  physical  signs  are 
an  unusual  number  of  rales  throughout  the  chest,  and  imperfect  res- 
onance, showing  that  some  lobules  are  collapsed. 

Pulmonary  Embolism  axd  Thrombosis. 

Pulmonary  embolism  consists  in  plugging  of  the  pulmonary  artery 
or  its  branches  by  coagula  formed  in  the  right  heart  or  in  the  veins. 
The  symptoms  depend  upon  the  size  of  the  occluded  vessel  and  upon 
the  nature  of  the  embolus — i.  e.,  whether  septic  or  not.  If  the  artery 
itself  is  plugged,  death  takes  place  suddenly  or  after  a  short  interval, 
with  symptoms  of  syncope  or  asphyxia. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  319 

Symptoms.  If  a  large  branch  is  plugged,  the  first  symptom  is  gen- 
erally intense  dyspnoea,  which  may  amount  to  an  agonizing  craving 
for  air.  Pain  in  the  chest,  which  may  or  may  not  be  acute,  is  com- 
plained of  and  may  be  referred  to  the  seat  of  the  embolus.  Cough 
is  not  a  common  symptom,  and  may  be  altogether  absent.  The  breath- 
ing is  considerably  altered;  it  is  usually  increased  in  frequency,  and 
may  be  much  hurried;  it  may  or  may  not  be  shallow,  and  while  the 
patient  can  take  a  deep  inspiration,  it  does  not  give  relief  to  his  dysp- 
noea.    At  times  it  is  irregular  and  gasping. 

The  face  is  pale  or  may  be  cyanosed,  and  is  apt  to  be  bathed  in 
perspiration.  The  veins  are  swollen  and  prominent,  The  heart's 
action  is  irregular  and  may  be  tumultuous.  Exophthalmos  has  been 
observed.  The  temperature  falls  below  normal,  but  a  febrile  rise  may 
occur  later.     The  intellect  is  unclouded. 

The  physical  signs  are  indefinite.  The  respiratory  murmur  is  rough- 
ened and  exaggerated  in  most,  but  not  in  all  cases.  Fox  states  that 
rades  are  very  rarely  heard.  Collapse,  oedema,  and  bronchitis  are  pos- 
sible results.  A  systolic  blowing  murmur  may  be  heard  over  the  heart 
and  pulmonary  artery,  and  in  protracted  cases  albuminuria  and  oedema 
may  be  met  with. 

When  the  embolus  is  septic,  a  septic  pneumonia  or  metastatic  abscesses 
are  probable  results  in  cases  not  immediately  fatal. 

When  the  emboli  produce  hemorrhagic  infarcts  the  symptoms  are 
milder  and  consist  principally  in  dyspnoea,  pulmonary  hemorrhage,  and 
palpitation.  The  onset  is  sudden  and  accompanied  by  a  fall  in  tempera- 
ture. The  physical  signs  indicate  consolidation,  if  the  pneumonia  or 
infarcted  area  is  of  moderate  size.  It  may  be  discovered  at  the  root 
of  the  lungs  in  the  inter-scapular  region. 

Haemoptysis  is  a  common  symptom  when  the  embolus  has  arisen  in 
the  heart.  The  amount  of  blood  varies  from  a  copious  expectoration 
to  the  rusty  sputum  seen  in  pneumonia;  it  may  persist  for  weeks. 
Pleurisy  and  pleural  effusion  are  frequent  complications;  chills  occur 
sometimes,  and  pneumonia,  with  corresponding  rise  of  temperature, 
may  develop. 

The  most  important  points  in  diagnosis  are  the  sudden  onset  of  the 
dyspnoea  and  other  pulmonary  symptoms,  and  the  detection  of  a  con- 
dition which  would  give  rise  to  emboli,  such  as  puerperal  fever  or 
heart  disease. 

Pneumonia. 

Acute  pneumonia,  croupous  or  lobar  pneumonia,  is  an  infectious 
inflammatory  disease  excited  by  the  micrococcus  lanceolatus  (diplococ- 
cus  pneumoniae,  pneumococcus)  involving  the  vesicular  structure:  of  the 
lungs,  and  followed  by  choking  of  the  alveoli  with  the  products  of 
inflammation  ;  it  is  attended  by  severe- constitutional  symptoms  due  to 
the  toxines  of  the  infecting  organism. 

Symptoms.  Mode  of  Onset.  The  invasion  of  pneumonia  is  usually 
sudden,  and  is  marked  by  a  chill.  The. temperature  rises  rapidly  and 
may  reach  104°  to  105°  in  the  first  twelve  hours  after  the  chill.  With 
the  fever,  the  patient  complains  of  severe  headache  and  pain  in  the  side, 


320  SPECIAL  DIAGNOSIS. 

and  has  a  short,  quick  cough  and  sometimes  vomiting.  The  pulse  is 
accelerated  moderately,  and  the  respiration  either  is  or  soon  becomes 
very  frequent.  The  face  is  apt  to  be  flushed,  and  there  may  be  a  cir- 
cumscribed red  spot  on  the  cheek.  The  skin  is  hot  and  dry.  On  phys- 
ical examination,  within  the  first  twenty-four  hours,  a  small  patch  of 
consolidation  is  detected,  which  may  subsequently  extend  over  a  large 
area. 

While  this  is  the  picture  of*  an  ordinary  pneumonia  in  its  early  stage, 
all  cases  are  by  no  means  so  clear.  In  some  the  course  resembles  that 
of  a  general  fever  in  which  the  pulmonary  disease  is  a  local  manifesta- 
tion. In  such  cases  there  may  be  prodromata,  consisting  of  headache, 
general  malaise,  a  slight  bronchitis,  and  digestive  disturbance.  Then 
follows  the  chill.  Central  pneumonia.  The  fever  may  be  high  for 
several  days  before  there  is  any  discoverable  consolidation  of  the  lungs, 
and  during  this  time  cough  may  be  wholly,  or  almost  wholly,  absent. 
The  respirations  increase  gradually  in  frequency,  and  finally  a  well- 
marked  pneumonia  can  be  made  out.  It  is  customary  to  account  for 
these  cases  by  the  supposition  that  pneumonia  developed  in  the  interior 
of  the  lung  and  consolidation  gradually  extended  to  the  surface.  In 
some  cases  the  patient  presents  no  more  definite  symptoms  for  three 
or  four  days  than  high  fever,  intense  headache,  and  moderately  acceler- 
ated respiration. 

Later  Stages.  At  the  end  of  forty-eight  hours,  or,  at  the  most,  of 
four  days,  the  patient  is  found  lying  in  bed  in  the  dorsal  position,  or  on 
the  affected  side.  The  face  is  flushed,  the  countenance  anxious,  the 
respiration  hurried,  the  alse  nasi  play  vigorously.  The  temperature 
varies  little  from  the  first  day's  rise ;  the  chest  pain  has  subsided,  the 
short,  dry  cough  is  now  attended  by  viscid  expectoration.  The  respira- 
tion continues  hurried,  the  pulse  full  and  bounding.  During  this  time 
the  physical  signs  of  consolidation  continue  and  increase. 

After  a  period  of  five  to  ten  days,  the  termination  takes  place  by 
crisis,  the  pain  in  the  chest  abates,  the  cough  becomes  looser,  and  the 
expectoration  more  free,  but  the  other  symptoms  persist.  In  addition, 
in  some  cases,  delirium  occurs,  the  pulse  softens  and  becomes  dicrotic, 
the  urine  becomes  albuminous. 

Respiratory  Symptoms.  Chest-pain,  cough,  hurried  respiration 
of  a  peculiar  type,  and  expectoration  are  characteristic.  The  chest-pain 
is  sharp  and  stabbing  or  lancinating.  It  is  increased  by  breathing.  It 
is  seated  about  the  nipple  or  in  the  axillary  region,  at  the  angle  of  the 
scapula  or  below  the  diaphragm.  Its  seat  always  indicates  the  side 
affected.  Cough  is  short  and  dry,  smothered  and  painful;  it^soon  be- 
comes softer  and  painless  as  the  expectoration  becomes  free.  It  may 
be  absent  in  the  feeble,  in  the  aged,  in  alcoholic  subjects,  or  in  persons 
with  brain  disease,  including  insanity.     . 

Characteristic  symptoms  of  pneumonia  are  the  increased  frequency 
and  the  type  of  the  respiration.  The  rate  in  adults  reaches  40,  50,  or 
even  60  per  minute,  and  in  children  80  and  100  are  not  very  uncommon. 

The  pulse,  on  the  contrary,  does  not  increase  in  frequency  iu  the 
same  proportion;  hence,  the  normal  ratio  of  respiration  to  pulse  of  1 
to  4  ceases,  and  becomes  1  to  3  or  1  to  2. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


321 


Inspiration  is  short,  expiration  quick  and  often  attended  by  an  ex- 
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tion instead  of  expiration.  In  children  both  are  so  short  that  unless 
the  epigastrium  is  inspected  it  may  be  difficult  to  distinguish  the  two. 


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Pneumonia.    Sudden  rise  ;  termination  by  crisis.     Pseudo-crisis  on  eighth  day. 

In  ordinary  ca-fes  which  run  a  normal  course  the  cough  is  followed 
by  expectoration,  which  is  at  first  viscid  mucus,  but  gradually  becomes 
reddish-brown  from  admixture  of  blood — the  rusty  sputum  of  pneu- 
monia. This  sputum  is  characteristic,  almost  pathognomonic.  It  is 
expelled  with  difficulty  from  the  mouth,  clinging  to  the  lips  or  to  the 
mustache.  It  cannot  be  removed  from  the  spit-cup  by  turning  it 
upside  down.  It  continues  to  be  rusty,  and  as  the  crisis  approaches 
becomes  purulent  and  is  discharged  with  ease.  In  typhoid  pneumonia 
it  jooks  like  prune-juice  (see  Sputum).  It  contains  blood,  alveolar 
epithelium,  the  specific  micrococcus,  and  later  pus  and  small  fibrinous 
casts. 

The  Fever.  The  chill  that  precedes  the  fever  is  pronounced  and 
is  always  a  warning  to  look  for  a  pulmonic  inflammation.  In  children 
a  convulsion  is  rarely  absent  in  frank  pneumonias.  During  its  occur- 
rence the  body-temperature  rises.  In  twelve  hours  it  reaches  104°  to 
105°.  It  remains  at  this  point,  obeying  the  laws  of  diurnal  variation. 
The  hot,  dry  skin,  the  parched  lips,  the  dry  tongue,  the  thirst,  the 
anorexia,  the  hurried  breathing,  the  occasional  delirium,  the  Loaded 
urine  attest  its  presence.  At  the  end  of  the  third,  or  more  frequently 
the  fifth,  seventh,  or  ninth  day,  crisis  takes  place;  the  fall  is  abrupt, 
and  the  normal  or  a  subnormal  temperature  may  be  reached  in  Prom  five 
to  fifteen  hours.      Pseudo-crises,  as  the  accompanying  chart  indicates, 

21 


322  •  SPECIAL  DIAGNOSIS. 

may  precede  the  true  crisis  by  twenty-four  or  forty-eight  hours.  The 
decline  may  take  place  by  lysis,  however.  Protracted  fever  indicates 
delayed  resolution  or  the  occurrence  of  a  complication. 

Cerebral  Symptoms.  In  some  cases,  especially  in  children,  the 
onset  of  the  disease  may  be.  marked  by  a  convulsion.  This  is  said  to 
occur  more  frequently  in  apical  pneumonias  than  in  pneumonias  of  the 
base.  Headache  and  delirium  are  so  pronounced  in  some  cases  as  to 
simulate  meningitis.  This  is  most  likely  to  be  the  case  in  severe  apical 
pneumonia  in  children,  and  in  double  pneumonia  either  in  children 
or  adults. 

Delirium  may  occur  during  the  height  of  the  fever,  and  occasion- 
ally is  maniacal.  Nocturnal  delirium  may  be  a  constant  symptom  in 
very  grave  cases.  In  drunkards  it  may  simulate  delirium  tremens, 
and  may  be  pronounced,  without  much  fever.  In  the  later  stages  of 
grave  or  fatal  cases  a  low  form  of  delirium,  with  a  tendency  to  coma, 
is  common. 

The  Heart  and  Pulse.  The  pulse  is  small  at  the  time  of  the 
chill,  but  becomes  full  and  bounding  during  the  fever;  later  it  may 
become  dicrotic.  The  pulse -respiration  ratio  has  been  referred  to. 
The  pulse  varies  in  frequency  and  in  character  with  the  type  of  the 
disease.  In  healthy  adults  it  is  rarely  over  110.  In  the  debilitated 
it  may  be  very  frequent,  small,  and  feeble;  in  the  aged,  frequent  .and 
dicrotic.  Extensive  consolidations  reduce  the  amount  of  blood  in  the 
general  circulation,  cause  rapid  action  of  the  heart  and  a  small  pulse, 
and  favor  death  with  the  heart  in  asystole. 

The  heart- sounds  are  clear.  A  murmur  low  in  pitch  is  often  heard 
in  the  mitral  and  pulmonary  areas.  The  left  ventricle  acts  forcibly.  The 
pulmonary  second  sound  is  accentuated.  If  dilatation  and  failure  of  the 
right  heart  take  place,  the  area  of  dulness  may  extend  beyond  the  right 
edge  of  the  sternum,  an  epigastric  impulse  be  noted,  turgescence  of  the 
veins  in  the  neck  become  marked,  but,  above  all,  the  previously  accent- 
uated pulmonic  second  sound  may  become  weak  or  disappear. 

Gastrointestinal  Symptoms.  Vomiting  frequently  occurs  in 
children  at  the  onset,  and  both  in  them  and  in  adults  may  persist  and 
mask  pulmonary  symptoms.  The  appetite  is  lest.  The  tongue  is 
furred.  It  may  become  dry  and  brown.  The  bowels  are  constipated 
except  when  complications  occur.  The  spleen  is  enlarged.  The  vom- 
iting and  epigastric  pain  may  be  so  pronounced  as  to  mask  the  pul- 
monary symptoms.  The  occasional  presence  of  jaundice  has  caused  it 
to  be  mistaken  for  hepatitis,  congestion  of  the  liver,  and  even  for  gall- 
stones. I  saw  a  case  of  pneumonia  said  to  be  appendicitis  and  peri- 
tonitis because  of  the  characteristic  pain,  colic,  and  vomiting;  followed 
by  great  abdominal  tenderness  in  the  upper  abdomen. 

The  Blood.  Leucocytosis  is  a  marked  attendant  upon  pneumonia, 
especially  in  cases  ending  favorably. 

Cutaneous  Symptoms.  Herpes  on  the  lips,  the  nose,  or  the  genitals 
is  of  common  occurrence.  Sweating  occurs  with  the  crisis,  or  if  heart 
failure  is  imminent. 

The  Urine.  The  urine  is  scanty  and  high-colored,  and  may  con- 
tain a  small  amount  of  albumin.     In  some  cases  the  chlorides  arc  found 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  323 

to  be  absent.  This  is  determined  by  acidulating  the  urine  with  a  drop 
or  two  of  nitric  acid;  and  then  adding  one  or  two  drops  of  a  10  per 
cent,  solution  of  silver  nitrate.  If  chlorides  are  present,  a  heavy  white 
cloud  of  chloride  of  silver  is  thrown  down.  The  chlorides  are  not 
invariably  absent,  or  even  diminished  in  pneumonia,  hence  their  reap- 
pearance, which  is  said  to  indicate  beginning  convalescence,  loses  its 
value  as  a  prognostic  sign. 

Physical  Signs.  Consolidation.  Diminution  in  the  amount  of 
air,  increase  of  solid  contents.  On  inspection,  diminished  movement. 
If  extensive  consolidation,  enlargement  of  the  affected  side.  On  pal- 
pation, inspection  confirmed  and  increased  vocal  fremitus  discovered. 
Both  are  more  marked  at  the  height  of  consolidation.  Percussion. 
In  first  stage,  impaired  resonance  or  Skodaic  resonance.  In  stage  of 
hepatization,  dulness  or  flatness,  but  without  any  wooden  quality  or 
marked  resistance. 

Auscultation.  In  the  early  stage,  that  of  congestion,  the  respiratory 
murmur  is  suppressed  and  crepitant  rales  are  heard  at  the  end  of  inspi- 
ration. On  full  inspiration  or  after  cough  a  broncho- vesicular  respira- 
tion is  brought  out.  When  consolidation  has  taken  place  the  respira- 
tory murmur  is  bronchial.  Rales,  if  present,  are  moist  suberepitant 
rales  from  associated  bronchitis,  or  a  few  crepitant  rales  may  still  per- 
sist, and  a  friction-sound  be  heard. 

When  resolution  sets  in,  the  crepitant  rale  reappears,  quickly  followed 
by  moist  suberepitant  rales,  heard  both  on  inspiration  and  expiration, 
while  dulness  gradually  yields  to  impaired  resonance.  The  respiration 
loses  its  bronchial  character  and  again  acquires  a  vesicular  element 
before  becoming  completely  normal.  It  may  be  a  week  or  two,  or 
many  months,  even  in  uncomplicated  cases,  before  the  percussion-note 
becomes  perfectly  clear,  and  rales  wholly  disappear. 

Duration  and  Course.  The  duration  of  the  disease  is  from  one 
to  two  weeks.  It  may  subside  by  crisis  on  the  third,  fifth,  seventh, 
or  ninth  day,  or  gradually  by  lysis.  Crisis  is  marked  by  a  critical 
sweat,  a  copious  discharge  of  limpid  urine,  or  sometimes  by  a  few  loose 
movements  of  the  bowels,  accompanying  a  fall  of  temperature  to  or 
below  normal. 

Instead  of  clearing  up,  the  pneumonia  may  progress  to  suppuration, 
abscess,  or  gangrene.  These  conditions  can  be  made  out  by  the  char- 
acter and  range  of  temperature,  the  general  condition  of  the  patient, 
the  sputum,  and  the  physical  signs.  Termination  in  abscess  or  gan- 
grene is  rare. 

In  cases  proceeding  to  a  fatal  issue  the  strength  fails,  respiration  be- 
comes more  labored,  and  expectoration  increasingly  difficult.  The 
number  of  respirations  often  diminishes,  but  the  pulse  continues  fre- 
quent and  often  becomes  small  and  irregular.  Physical  examination 
shows  diffuse  bronchitis  with  oedema.  The  heart's  action  is  irregular 
and  rapid.  The  sounds  are  weak  and  feeble;  the  first  becomes  short  and 
snappy  like  the  second,  and  later  both  are  weak  or  indistinct.  Death 
may  occur  abruptly  from  convulsion,  or  more  frequently  from  asphyxia, 
due  to  <edema  of  the  lungs,  which  in  turn  sets  in  on  account  of  weak- 
ness of  the  heart  or  the  development  of  heart-clot  from  cardiac  asystole. 


324  SPECIAL  DIAGNOSIS. 

Varieties.  Migratory  pneumonia.  Sometimes,  with  the  reap- 
pearance of  abundant  rales  and  increased  expectoration,  the  fever  con- 
tinues high,  or,  if  the  temperature  have  fallen  to  normal,  again  rises, 
the  patient  is  disinclined  to  take  food,  has  a  dry,  brown  tongue,  and  is 
often  delirious.  In  such  cases  the  pneumonia  is  probably  extending 
in  the  lung  already  involved,  or  has  attacked  the  other  lung. 

Typhoid  -pneumonia  is  an  unfortunate  name  for  an  adynamic  form  of 
the  disease  with  typhoid  symptoms.  If  it  arises  in  the  course  of,  or 
complicates,  low  fevers,  it  is  usually  of  the  typhoid  type;  but  it  occurs 
also  in  those  much  exhausted,  in  depraved  health,  or  exposed  to  unhy- 
gienic surroundings.  It  is  found  also  in  cases  of  septicaemia,  in  Bright' s 
disease,  in  drunkards,  and  in  the  negroes  in  the  southern  part  of  the 
United  States. 

The  characteristic  features  of  this  form  of  pneumonia  are  the  great 
physical  prostration  and  the  weak  heart-action.  The  fever  is  high, 
the  respiration  and  pulse  frequent,  and  delirium  and  vomiting  are  more 
frequent  than  in  the  ordinary  form.  The  skin  sometimes  has  a  dusky 
hue;  the  tongue  is  heavily  coated,  or  may  be.  dry  and  brown,  and 
sordes  collect  on  the  teeth.  The  sputa  may  be  rusty,  and  sometimes 
pure  blood  is  expectorated.  The  disease  may  prove  fatal  rapidly,  or 
may  linger  for  a  long  time,  the  patient  only  gradually  coming  out  of  a 
low  typhoid  state.     It  is  always  dangerous. 

Bilious  pneumonia  is  the  name  given  to  a  type  of  pneumonia  occur- 
ring in  persons  who  are  already  suffering  from  malarial  poisoning.  The 
initial  chill  lasts  longer,  and  the  pain  in  the  side,  from  coincident 
pleurisy,  is  more  marked  than  in  ordinary  pneumonia.  The  fever  is 
more  remittent,  and  jaundice  and  vomiting  are  present. 

Diagnosis.  The  diagnosis  is  based  upon  the  aggregation  of  special 
symptoms.  The  mode  of  onset,  the  chill,  the  course  of  the  fever,  the 
pain  in  the  chest,  the  cough,  the  peculiar  expectoration,  the  dyspnoea, 
the  abnormal  pulse  respiration  ratio,  the  peculiar  character  of  breath- 
ing, and  the  physical  signs  are  common  symptoms.  It  must  be  remem- 
bered that  in  children,  in  the  aged,  in  drunkards,  in  cases  of  chronic 
disease,  the  type  is  different.  In  drunkards  cerebral  symptoms  are 
more  marked.  In  children  the  cerebral  symptoms  are  more  prom- 
inent, the  expectoration  often  absent.  In  the  aged,  the  cough,  the 
expectoration,  and  the  fever  are  not  pronounced;  the  former  may 
be  absent;  the  onset  is  insidious.  The  same  onset  and  course  occur 
in  wasting  diseases,  as  cancer,  phthisis,  Blight's  disease,  diabetes, 
and  organic  heart  disease.  In  this  class  of  cases  a  small  patch  of 
pneumonia,  difficult  to  determine  on  physical  examination,  may  be 
attended  by  the  gravest  general  symptoms.  In  all  of  the  above  cases, 
if  there  is  fever  without  cause,  although  no  pulmonary  symptoms  are 
present,  the  lungs  must  be  examined  repeatedly.  In  many  such  cases 
the  physical  signs  are  obscured  because,  respiratory  action  is  enfeebled 
by  the  primary  condition. 

Pneumonia  must  be  distinguished  from  other  acute  inflammatory 
affections  of  the  lung  and  pleura  and  from  acute  tuberculo-pneumonic 
phthisis.  The  evidence  for  each  is  considered  in  the  respective  sections. 
The  presence  of  leucocytes  serves  to  distinguish  it  from  acute  tubereu- 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  325 

losis  and  from  typhoid  fever,  meningitis,  and  influenza.  To  distinguish 
pneumonia  from  pleurisy  with  effusion,  the  aspirator  may  be  used. 

Bacteriological  Diagnosis.  Staining  and  microscopical  examination 
of  the  sputum  reveal  the  characteristic  micro-organism.  Care  must 
be  taken  to  secure  the  sputum  from  the  lung.  By  inoculation  of  rabbits 
with  the  sputum  the  disease  is  readily  reproduced.  The  organism  is  not 
readily  found  in  the  blood. 

Complications.  The  complications  which  occur  in  the  course  of 
the  disease,  modifying  the  clinical  picture  and  obscuring  the  diagnosis, 
are  :  pleurisy  with  serous  or  purulent  exudation,  pericarditis,  endocar- 
ditis, meningitis,  and  jaundice. 

Broncho-pneumonia,  or  Catarrhal  Pneumonia,  is  a  pneu- 
monia occurring  secondarily  to  bronchitis,  and  is  characterized  by  the 
development  of  areas  of  consolidation  in  both  lungs,  and  the  persist- 
ence of  a  bronchitis  of  the  middle-sized  or  smaller  tubes.  In  propor- 
tion as  the  areas  of  consolidation  are  large,  the  symptoms  and  physical 
sigus  approach  those  of  lobar  pneumonia.  It  is  more  common  in  chil- 
dren and  in  debilitated  persons.  It  is  the  chief  form  in  infants.  1. 
It  is  frequently  secondary  to  measles,  diphtheria,  scarlet  fever,  and 
pertussis.  2.  As  aspiration-pneumonia,  it  occurs  when  food,  septic 
particles,  blood,  or  tissue  enter  the  lungs  during  the  loss  of  sensibility 
of  the  larynx  in  apoplectic,  ursemic,  or  other  forms  of  coma,  and  in 
operations  about  the  upper  air-passages  and  mouth.  It  is  a  fatal  com- 
plication of  tracheotomy.      3.    It  is  frequently  of  tuberculous  origin. 

Catarrhal  "pneumonia,  except  the  aspiration-form,  develops  gradually, 
and  it  may  not  always  be  easy  to  mark  the  point  at  which  the  bron- 
chitis which  precedes  merges  into  pneumonia;  but  as  a  rule  there  are 
more  or  less  chilliness  (rarely  a  decided  chill)  and  an  access  of  fever. 
There  is  usually  greater  prostration  than  in  the  lobar  form,  in  propor- 
tion to  the  amount  of  pneumonia  present.  The  pulse  is  more  frequent 
and  more  likely  to  be  feeble.  Cough  and  expectoration  are  marked 
symptoms.  The  sputum  is  tenacious  and  glairy,  not  rusty.  It  contains 
streptococci  and  staphylococci  in  much  greater  numbers  than  are  found 
in  ordinary  bronchitis;  fatty  epithelial  cells,  epithelium,  fat-globules,  and 
diplococci.  Dyspnoea  is  more  extreme  than  in  lobar  pneumonia.  The 
respirations  are  excessively  rapid — -60  to  80  per  minute;  cyanosis  rapidly 
ensues.  The  fiuger-tips  become  blue,  the  face  dusky.  The  fever  does 
not  rise  as  high  as  in  the  lobar  form.  At  first  the  skin  is  hot  and  dry; 
later  it  becomes  cold  and  clammy,  and  in  the  tuberculous  form  sweats 
are  common.  The  duration  of  the  disease  is  usually  much  longer  than 
in  lobar  pneumonia. 

The  physical  signs  arc  those  of  bronchitis,  with  here  and  there  larger 
or  smaller  areas  of  consolidation,  over  which  the  rales  arc  finer  and 
closer  set;  the  percussion-note  is  dull,  and  the  respiratory  murmur 
bronchial  or  broncho-vesicular.  An  entire  lobe  may  be  consolidated. 
Areas  of  collapse  and  portions  more  or  less  cedematous  combine  t<> 
make  the  more  complex  physical  signs.  WTiileboth  lung-  areaffected, 
they  are  not  usually  affected  to  the  same  extent.  It  is  said  that  the 
apices  are  more  prone  to  involvement  in  this  than  in  the  lobar  form; 
and  some  writers  (Osier)  look  upon  it  as  a  form  of  phthisis. 


326  SPECIAL  DIAGNOSIS. 

In  the  common  form  seen  in  infants  the  symptoms  of  asphyxia  set  in 
at  variable  periods  in  the  course  of  the  disease.  General  cyanosis  super- 
venes. Stupor  sets  in,  the  hurried  respirations  grow  shorter  and  more 
gasping,  the  pulse  becomes  excessively  rapid  and  feeble,  the  extremities 
cool  and  clammy;  with  the  stupor  the  cough  abates  and  the  breathing 
becomes  more  shallow.  The  lungs  fill  up  with  fluid  mucus,  and  the  child 
drowns  in  its  own  secretions,  or  cardiac  paralysis  sets  in  after  dilatation 
of  the  right  heart. 

Diagnosis.  The  affection  is  distinguished  (1)  by  its  pathological 
antecedents  and  causal  relations;  (2)  its  gradual  onset;  (3)  its  distribu- 
tion in  both  lungs;  (4)  the  preponderance  of  physical  signs  of  bronchitis 
over  those  of  consolidation;  (5)  the  extreme  dyspnoea  and  cyanosis  with 
a  lower  temperature  than  in  lobar  pneumonia;  (6)  the  onset  of  carbon- 
dioxide-poisoning;  (7)  the  long  duration  and  gradual  decline.  The 
tuberculous  form  is  distinguished  by  (1)  the  history  of  exposure  to 
infection  or  of  a  focus  of  infection  in  the  body,  glands,  or  joints;  (2) 
the  longer  course;  (3)  delayed  asphyxia:  (4)  rapid  emaciation;  (5)  dif- 
fused sweats ;  (6)  physical  signs  of  consolidation  and  subsequently  of 
cavity  at  the  apex;  and  (7)  absolutely  by  tubercle  bacilli  in  the  expec- 
toration coughed  up  or  vomited.  I  have  seen  a  child  aged  fifteen 
months,  of  a  tuberculous  mother,  completely  recover.  The  tuberculous 
form  is  common  in  colored  infants. 

Chronic  Interstitial  Pneumonia. 

Cirrhosis,  fibroid  phthisis,  and  chronic  interstitial  pneumonia  are 
names  given  to  a  condition  of  chronic  induration  of  the  lung,  caused 
by  an  interstitial  overgrowth  of  fibrous  tissue.  Obliteration  of  the 
air-vesicles  and  contraction  of  the  lung  result  from  the  overgrowth. 
The  bronchi  are  frequently  dilated,  and  cavities  and  gangrene  may 
occur.  The  disease  is  rare  except  as  the  result  of  tubercle,  but  it  may 
follow  pneumonia  and  pleurisy,  and  it  is  said  to  be  caused  by  the  inha- 
lation of  fine  particles  of  steel  or  cotton.  Pneumonokoniosis  is  the 
term,  first  employed  by  Zenker,  for  the  chronic  interstitial  pneumonia 
from  the  inhalation  of  dust. 

Physical  Signs.  Inspection.  The  disease  is  unilateral.  The  chest- 
wall  is  retracted.  The  ribs  are  drawn  together  so  that  the  interspaces 
are  obliterated.  The  shoulder  is  drawn  over  the  sunken  thorax.  The 
spinal  column  is  curved.  The  heart  is  displaced.  Jt  is  drawn  toward 
the  affected  side.  If  the  right  lung  is  the  seat  of  disease,  an  impulse 
is  seen  to  the  right  of  the  sternum ;  if  the  left,  the  precordial  area  of 
impulse  is  increased  and  extends  upward.  There  is  no  expansion  what- 
soever (immobility)  of  the  affected  apex  or  base.  The  healthy  lung  is 
the  seat  of  compensatory  emphysema. 

Palpation.  Inspection  is  confirmed.  Fremitus  is  increased,  espe- 
cially at  the  apex.     At  the  base,  pleural  thickening  lessens  the  fremitus. 

Percussion.  The  physical  signs  show  increased  density  of  lung 
tissue,  with  dulness  on  percussion,  or,  over  a  dilated  bronchus,  a  tym- 
panitic or  amphoric  note. 

Auscultation.    The  respiratory  murmur  is  bronchial,  or,  over  a  dilated 


DISEASES  OF  THE  LUNGS  AXD  PLEUBJE.  327 

bronchus,  has  a  hollow  sound.  At  the  base  breath-sounds  are  feeble, 
distant,  or  absent.      Rales  are  also  heard. 

The  disease  runs  a  very  chronic  course  attended  by  cough,  and  muco- 
purulent and  sometimes  bloody  expectoration,  even  hemorrhage;  but 
there  is  no  fever  and  not  much  loss  of  flesh.  Dyspnoea  occurs  on 
ascending  heights  only.  Dilatation  of  the  right  heart  is  likely  to 
ensue,  with  cardiac  murmurs  and  increased  lateral  dulness  and  increase 
of  dyspnoea.  Death  is  hastened  by  the  disease,  and  is  often  brought 
on  by  acute  pneumonia. 

In  pneumonokoniosis  (also  known  as  anthracosis,  coal-miner's  disease; 
siderosis,  from  metallic  dust;  chalicosis,  from  mineral  dust,  as  in  stone- 
cutter's phthisis)  there  is  a  history  of  exposure  to  the  irritating  parti- 
cles for  a  considerable  period,  during  which  time  cough  develops, 
gradually  increases,  and  the  general  health  fails.  Emphysema  simul- 
taneously arises,  causing  dyspnoea.  The  patients  wheeze,  rough  in 
paroxysms,  and  expectorate  sputum  which  contains  the  dust-particles. 
In  anthracosis  it  is  black.  On  microscopical  examination  the  special 
dust-particles  are  often  found.  The  symptoms  of  emphysema  and 
chronic  bronchitis  predominate.  Tubercular  infection  may  take  place 
late  in  the  disease. 

Pulmonary  Tuberculosis. 

For  convenience  of  diagnosis  the  specific  inflammation  of  the  lungs 
caused  by  the  bacillus  tuberculosis  will  be  considered  in  this  section. 
If  a  strict  ^etiological  classification  were  followed,  it  would  be  consid- 
ered among  the  infectious  diseases. 

Clinically,  we  see  tuberculosis  in  the  lungs  manifesting  itself  in  one 
of  the  forms  of  acute  pneumonic  phthisis,  acute  miliary  tuberculosis, 
and  chronic  ulcerative  phthisis. 

Definition.  Tuberculosis  of  the  luugs,  pulmonary  phthisis,  and 
consumption  are  names  applied  to  an  infectious  and  mildly  contagious 
disease  of  the  lungs,  caused  by  the  tubercle  bacillus,  appearing  in  an 
acute  and  chronic  form,  and  characterized  by  cough,  fever,  sweats, 
more  or  less  rapid  emaciation,  purulent  expectoration  containing  elastic 
fibres  and  tubercle  bacilli,  and  by  peculiar  physical  signs. 

Acute  Pulmonary  Tuberculosis,  Acute  Phthisis,  Acute 
Pneumonic  Phthisis,  or  Galloping  Consumption,  may  be  pri- 
mary, or  be  secondary  to  a  localized  area  in  the  lung  causing  rapid 
infection,  or  to  tubercular  pleurisy,  tubercular  peritonitis,  or  tubercu- 
losis of  some  other  organ.  Its  onset  is  usually  marked  by  cough,  fever 
with  or  without  chills,  dyspnoea,  and  sometimes  haemoptysis.-  The 
fever  rises  to  103°  or  104°,  and  is  of  a  continued  type,  or  rapidly 
assumes  a  hectic  type,  accompanied  by  restlessness  and  exhausting 
nig] it-sweats,  anorexia,  and  rapid  emaciation.  Prostration  is  extreme, 
but  the  mind  is  at  first  clear  and  the  spirits  cheerful.  Cough  increases, 
the  expectoration,  at  first  mucoid  and  scanty,  but  often  tinged  with 
blood,  becomes  more  copious  and  muco-purulent.  The  bowels  may  be 
loosened  or  constipated.     The  urine  may  show  the  diazo-reaction. 

When  death  takes  place  without  more  decided  pulmonary  symptoms, 


328  SPECIAL  DIAGNOSIS. 

the  tuberculosis  has  been  secondary  to  tuberculosis  elsewhere,  or  death 
is  the  result  of  a  general  miliary  tuberculosis. 

When  the  acute  pulmonary  tuberculosis  is  primary,  the  character  of 
the  disease  is  soon  made  clear  by  the  early  development  of  consolida- 
tion of  the  lungs,  usually  of  an  apex  first,  rapidly  followed  by  soften- 
ing and  the  formation  of  cavities.  The  sputum  becomes  muco-purulent, 
is  frequently  streaked  with  blood,  and  pure  blood  is  often  coughed  up. 
The  sputum  contains  yellow  elastic  tissue  and  abundant  tubercle  bacilli. 
The  patient  often  presents  a  cachectic  appearance;  emaciation  has 
been  very  rapid,  and  has  reached  an  extreme  degree;  there  is  frequently 
a  red  flush  about  the  cheek-bones,  which,  with  the  bright  eyes,  contrasts 
strongly  with  the  hollow  cheeks  and  temples,  and  the  white  wasted 
hands  and  clubbed  fingers  with  bluish  nails. 

The  patient's  mental  attitude  is  often  peculiarly  and  characteristic- 
ally hopeful.  He  expresses  himself  as  better  each  day,  though  he  is 
occasionally  subject  to  despondency,  and  is  sure  that  if  he  could  only 
gain  a  little  strength  he  would  soon  be  well. 

Sometimes,  especially  in  children,  the  disease  is  latent.  The  patient 
suffers  from  weariness,  the  cheeks  flush  easily,  the  pulse  is  readily  dis- 
turbed, there  are  nocturnal  fever  and  occasional  sweats.  Emaciation 
proceeds  very  gradually,  and  a  long  time  may  elapse  before  any  disease 
is  demonstrable. 

In  a  few  cases  the  cerebral  symptoms  are  so  pronounced  as  to  mask 
the  pulmonary,  and  in  other  cases  there  is  actual  coincident  involve- 
ment of  the  cerebral  meninges. 

The  physical  signs  are  those  of  consolidation,  often  without  conjoint 
pleurisy.  The  apex  is  usually  first  invaded.  There  are  diminished 
movement,  increased  fremitus,  and  dulness  on  percussion.  At  first 
the  breathing  is  broncho-vesicular.  It  rapidly  becomes  bronchial. 
At  first  small  moist  rales  are  detected.  Later  they  become  large  and 
gurgling.  A  pleural  friction  may  be  heard.  It  may  be  first  heard 
above  the  spine  of  the  scapula  behind,  above  the  clavicle  in  front,  or 
high  up  in  the  axilla.  The  upper  lobe  of  the  right  lung  may  be 
affected  first,  or  the  anterior  portion  of  the  middle  lobe.  The  physical 
signs  may  be  observed  first  in  the  axillary  region  of  either  side.  The 
consolidation  extends  to  the  remainder  of  the  lung,  being  preceded  by 
physical  signs  indicating  gradual  encroachment  upon  the  air-containing 
structure.  The  respiratory  murmur  is  harsh,  but  soon  becomes  broncho - 
vesicular  and  then  bronchial.  As  consolidation  progresses  in  the  middle 
and  lower  portions  of  the  affected  lung,  signs  of  cavity  or  multiple 
cavities  app  ar  in  the  upper.  (The  whole  of  a  lobe  may  be  the  seat 
of  small  cavities  filled  with  muco-purulent  or  purulent  fluid.)  Cavern- 
ous breathing  and  pectoriloquy,  or  the  bronchial  sniff  of  consolidation, 
become  more  pronounced.  The  dull  note  of  consolidation  is  relieved 
by  a  dull  tympanitic  or  full  tympanitic  note.  Now  moist  rales  of  all 
degrees  are  heard.  Above  they  are  gurgling;  below,  small  and  large 
moist  rales.  If  the  progress  is  not  too  rapid  throughout  the  lung  first 
affected,  signs  of  invasion  are  found  in  the  remaining  lung,  usually  at 
a  point  corresponding  to  the  primary  focus  in  the  original  lung.  The 
apex,  therefore,  is  first  invaded  in  most  cases.      Infection  of  the  second 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  329 

may  begin  earlier  than  the  signs  in  the  first  lung  would  lead  one  to 
anticipate.  The  rapid  invasion  of  one  lung  compels  compensatory  emphy- 
sema of  the  other.  The  increased  movement,  with  harsh  or  puerile 
breathing,  without  change  in  fremitus  or  in  pitch  and  tone  on  percus- 
sion, masks  any  small  consolidations. 

The  expectoration  becomes  more  purulent  as  the  disease  progresses, 
and  may  be  blood-tinged.  It  is  copious  and  possesses  some  f  oetor.  It 
is  found  to  swarm  with  bacilli  and  to  contain  yellow  elastic  tissue. 
Hemorrhage  may  take  place.  The  general  symptoms  become  more 
alarming.  The  fever  becomes  of  a  hectic  type.  The  patient  rapidly 
emaciates.  Cyanosis  is  shown  in  the  dusky  countenance  and  blue  finger- 
tips. The  exhaustion  becomes  extreme.  Pallor,  with  flushed  cheeks 
and  an  anxious  countenance,  is  seen.  The  sweats  are  profuse.  The 
appetite  is  lost.  Diarrhoea  may  set  in.  Remissions  may  take  place, 
even  in  acute  cases;  for  a  time  the  fever  and  more  aggravated  pulmo- 
nary symptoms  are  in  abeyance.  The  typhoid  state  ensues  in  some  cases. 
Death  takes  place  from  exhaustion  and  heart-clot  or  from  meningeal 
tuberculosis.     The  duration  is  from  two  to  six  weeks. 

Diagnosis.  In  the  earliest  stages,  before  the  invasion  of  new  terri- 
tory is  pronounced,  the  cases  are  involved  in  doubt.  It  may  be  con- 
founded with  pneumonia  until  the  sputum  is  secured  and  bacilli  are 
found. 

In  pneumonia  we  have  the  pronounced  rigor,  the  rapid  rise  of  tem- 
perature, the  altered  pulse-respiration  ratio,  the  hot,  dry  skin,  the 
sticky,  viscid  sputum,  containing  the  pneumococcus,  the  peculiar  changes 
in  the  urine,  leucocytosis,  the  occurrence  of  herpes,  the  termination  by 
crisis,  to  point  to  the  nature  of  the  process.  The  sputum  is  more  pur- 
ulent in  acute  pneumonic  phthisis.  Then  cavity-formation  does  not  take 
place,  or  at  least  rarely.  Emaciation  is  not  marked;  there  are  no  such 
profuse  sweats  as  the  repeated  drenchings  we  see  in  pneumonic  phthisis ; 
anaemia  is  not  so  pronounced.  In  pneumonia  the  fever  is  of  a  contin- 
ued type;  in  phthisis  it  is  often  intermittent  or  remittent.  Finally, 
the  history  of  exposure  to  infection,  the  primary  occurrence  of  tuber- 
culosis elsewhere,  the  secondary  occurrence  of  tuberculosis  in  other 
organs  after  the  lung-invasion,  the  longer  duration — aid  in  determining 
the  true  affection.  Inoculation  of  animals  may  be  resorted  to  in 
doubtful  cases. 

Acute  Miliary  Tuberculosis  is  attended  by  high  fever,  rapid 
emaciation,  hurried  breathing,  rapid  pulse,  duskiness  of  face  and 
extremities,  more  or  less  stupor,  delirium,  and  the  development  of  the 
typhoid  state,  with  prostration  and  the  occurrence  of  profuse  sweats. 
Intestinal  symptoms,  as  flatulency  and  distention,  may  be  pronounced. 
and  diarrhoea  may  form  a  prominent  feature.  Physical  signs  are  nega- 
tive or  are  those  of  bronchitis.  There  is  resonance  or  hyper  resonance 
on  percussion.  The  latter  is  not  uncommon.  The  onset  is  abrupt  or 
may  follow  a  period  of  malaise.  In  some  instances  the  tuberculous 
process  is  more  advanced  in  some  situations  than  in  others,  giving  rise 
to  special  local  symptoms.  Thus,  recently,  a  patient  was  admitted  to 
the  Presbyterian  Hospital  with  stupor  and  moderate  delirium.  He 
had  fever,  rapid  pulse  and  breathing,  and  a  peculiar  dry,  harsh  skin. 


330  SPECIAL  DIAGNOSIS. 

There  were  albuminuria,  casts  and  blood  in  the  urine,  and  it  was  thought 
lie  had  uraemia.  The  temperature -range  was  irregularly  intermittent. 
The  diagnosis  was  established  later  because  of  the  development  of 
undoubted  secondary  tuberculosis  in  other  organs.  At  the  autopsy 
general  tuberculosis  was  found,  with  primary  tuberculous  ulceration  in 
the  bladder,  the  ureters,  and  renal  pelves. 

Diagnosis.  Hurried  breathing  and  cyanosis  are  distinctive  features, 
out  of  all  proportion  to  the  physical  signs,  and,  on  this  account,  of 
diagnostic  significance.  It  must  be  distinguished  from  typhoid  fever, 
septicaemia  or  pyaemia,  and  malignant  endocarditis.  From  typhoid 
fever  it  is  distinguished  by  the  absence  of  successive  stages  in  the 
course  of  the  disease;  in  typhoid  fever  the  evolution  of  the  disease  is 
more  characteristic  than  its  symptoms.  The  headache  of  the  first  week 
finally  disappearing,  is  noteworthy.  The  special  range  of  temperature, 
the  onset,  the  fastigium,  and  the  defervescence  at  definite  periods  in 
the  evolution  of  the  disease,  are  of  diagnostic  value.  Cyanosis  is 
more  constant  and  marked  in  tuberculosis.  The  skin  and  capillaries 
have  more  tone  in  typhoid  fever  than  in  tuberculosis,  at  least  in  the 
first  two  weeks.  Hypersemia  follows  irritation  in  typhoid;  pallor, 
with  duskiness,  in  tuberculosis.  The  eruption,  with  its  specific  mode 
of  development,  belongs  to  typhoid  fever  alone.  The  stools,  the 
enlarged  spleen,  the  vascular  tone  are  suggestive  of  typhoid  fever. 
The  spleen  enlarges  earlier  in  the  disease  in  typhoid  fever.  Bacterio- 
logical examination  may  be  of  service.  The  occurrence  of  intestinal 
hemorrhage,  pointing  as  it  does  to  typhoid  fever,  is  a  welcome  sign 
in  cases  in  which  the  diagnosis  is  obscure.  I  have  never  seen  it  in 
tuberculosis.  In  typhoid  fever  the  reflexes  (knee-jerk)  are  never  ab- 
sent; in  tuberculosis,  if  the  meninges  are  iuvolved,  they  are  variable, 
present  one  day,  absent  the  next.  The  diazo-reaction  in  typhoid  is  of 
some  service,  although  it  also  occurs  in  tuberculosis  (see  Urine).  It 
does  not  come  on  until  later  than  the  fifth  day  in  typhoid  fever.  It 
disappears  at  a  certain  time  in  the  involution  of  typhoid;  it  continues 
indefinitely  in  tuberculosis. 

The  distinction  of  tuberculosis  from  septicaemia  or  pyaemia  and  malig- 
nant endocarditis  is  often  difficult.  We  must  search  for  local  areas  of 
septic  or  pyaemic  infection.  The  ears,  the  teeth,  the  bones,  the  veins, 
the  heart,  the  pelvic  organs  in  females,  the  rectum,  the  genito-urinary 
tract — must  be  carefully  examined.  Hemorrhagic  infarcts,  or  meta- 
static abscesses,  may  be  found  which  point  to  the  original  conditions. 
The  eye-ground,  may  show  hemorrhages.  The  skin  and  mucous  mem- 
branes may  exhibit  minute  capillary  hemorrhages  or  infarcts.  They 
are  of  the  size  of  a  pin-head,  do  not  disappear  on  pressure,  and  are 
not  elevated.  The  spleen  is  more  likely  to  be  enlarged  in  the  septic 
affections.  The  respirations  are  not  so  rapid  as  in  tuberculosis.  Cyano- 
sis is  a  distinctive  feature  of  tuberculosis.  The  physical  signs  of  endo- 
carditis may  be  determined,  and  subsequently  embolism  or  thrombosis 
prove  the  nature  of  the  process. 

Chronic  Tuberculosis  ;  Chronic  Ulcerative  Phthisis. 
Chronic  tuberculosis  or  phthisis  is  much  more  common  than  acute 
tuberculosis,  from  which  it  is  distinguished  by  its  slow  progress  and 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  331 

by  periods  of  remission  during  which  the  disease  may  be  arrested  tem- 
porarily or  permanently. 

It  may  be^in  in  a  variety  of  ways.  The  most  common  mode  of 
origin  is  in  an  ordinary  bronchitis  with  which  pleurisy  is  occasionally 
associated.  Previous  to  this  the  patient  may  have  been  in  good  health, 
but  generally  the  health  has  been  impaired  for  some  time.  The  bron- 
chitis may  be  simple  or  part  of  influenza,  measles,  whooping-cough,  or 
some  other  specific  disease. 

The  bronchitis  usually  proves  obstinate,  and  by  and  by  there  is  found 
at  the  apex  of  the  lung  a  small  area  over  which,  on  percussion,  there 
is  increased  resistance,  with  slight  impairment  of  resonance,  as  com- 
pared with  the  other  side;  the  respiratory  murmur  is  broncho-vesicular, 
sometimes  jerky  in  rhythm,  and  the  vocal  resonance  and  fremitus 
slightly  increased  or  unaltered.  Such  physical  signs  are  met  with  more 
frequently  at  the  right  apex  than  at  the  left,  and  oftener  in  the  supra- 
scapular fossa  than  anteriorly.  The  next  most  frequent  seat  is  probably 
between  the  clavicle  and  second  rib  anteriorly. 

The  patient  will  be  found  to  have  lost  strength,  and  usually  some 
weight.  There  is  often  a  slight  evening  rise  of  temperature,  and  occa- 
sionally nocturnal  perspirations.  The  appetite  is  impaired,  and  anorexia 
may  exist.  Cough  is  rarely  absent,  especially  during  the  night  or  on 
waking  in  the  morning;  it  may,  however,  be  so  slight  as  apparently 
to  have  escaped  the  notice  of  the  patient.  When  characteristic  it  is  dry 
and  hacking.  Expectoration  is  scanty  and  mucoid,  but  occasionally  it 
may  be  tinged  with  blood.  It  should  be  remembered  that  children 
and  old  persons  sometimes  do  not  expectorate,  and  that,  as  a  rule, 
women  are  more  inclined  to  suppress  expectoration  than  men.  No 
tubercle  bacilli  may  be  found  in  the  sputum  after  rej)eated  examina- 
tion ;  but  if  examinations  are  continued,  they  will  appear  sooner  or 
later. 

Instead  of  developing  after  a  bronchitis,  as  we  have  just  described, 
it  may  set  in  suddenly  under  the  guise  of  a  pneumonia,  more  frequently 
of  the  catarrhal  form.  The  symptoms  and  physical  signs  do  not  differ 
essentially  from  those  of  pneumonia  except  that  the  expectoration  is 
more  likely  to  be  profuse,  muco-purulent  and  blood-streaked,  and  bacilli 
are  found  in  it;  the  fever  is  more  hectic  in  type,  and  night-sweats  are 
common.  The  consolidation  is  found  at  the  apex.  After  the  patient 
convalesces  from  such  an  attack  he  continues  weak,  does  not  gain  flesh 
readily,  still  has  a  cough  with  expectoration,  evening  fever  with  occa- 
sional night-sweats,  and  an  area  of  consolidation  usually  at  an  apex  of 
the  lung.  Over  this  area,  in  addition  to  the  usual  signs  of  consolida- 
tion (bronchial  or  feeble  breathing,  dulness,  etc.),  moist  or  dry  sub- 
crepitant  rales  are  heard. 

In  some  cases,  fever,  emaciation,  and  weakness  progress  for  some 
time  before  pulmonary  symptoms  arise 

In  still  other  cases  the  invasion  of  the  disease  is  by  sudden  haemop- 
tysis, which  is  oftener  copious  than  not.  Several  such  hemorrhages 
may  occur  in  rapid  succession,  or  there  may  be  only  one  Moreover, 
ii^  disappearance  may  not  be  followed,  or  at  least  not  immediately,  by 
any  further  pulmonary  symptoms  or  physical  signs;  more  commonly, 


332  SPECIAL  DIAGNOSIS. 

however,  it  is  followed  by  fever,  cough,  expectoration,  and  physical 
signs  of  incipient  consolidation,  usually  at  the  apex. 

In  still  other,  but  rarer  cases,  the  pulmonary  disease  is  latent,  being 
marked  by  gastric  or  peritoneal  symptoms,  or  by  a  general  anamiia. 

By  whatever  path  invasion  comes,  the  physician  should  be  on  the 
lookout  for  it,  especially  in  a  young  adult  predisposed  by  heredity  or 
environment  to  tuberculosis.  The  recognition  of  the  disease  in  its  early 
stage  requires  the  greatest  skill,  which  in  turn  is  recompensed  with  the 
highest  reward,  since  the  disease  is  then  curable. 

The  further  progress  of  a  case  of  tuberculosis  of  the  lungs,  after 
consolidation  has  once  become  manifest,  is  very  variable.  It  may  be 
arrested  at  this  point  permanently,  cure  resulting  from  cicatrization. 
More  frequently  there  is  temporary  arrest  of  the  process;  fever  lessens 
or  ceases  entirely,  the  pulse  resumes  its  normal  rate,  appetite  improves, 
and  there  is  a  gain  in  flesh  and  strength.  Cough  and  expectoration 
are  more  likely  to  persist  than  the  other  symptoms,  but  with  the  other 
improvement  they  diminish  in  frequency  and  copiousness.  There  are 
fewer  rales,  but  the  sii>ns  of  consolidation  are  still  present,  though 
there  is  no  further  extension  of  the  process.  Often,  after  a  cavity  has 
been  found,  the  disease  is  arrested,  or  progresses  very  slowly. 

After  a  longer  or  shorter  time,  as  the  result  of  re-infection  from  the 
old  focus  excited  by  acute  bronchitis  or  by  some  depressing  influence, 
the  tuberculosis  is  re-lighted,  so  to  speak,  and  runs  much  the  same 
course,  the  lung  being  left  more  diseased  and  the  general  health  worse 
after  every  such  attack.  jSTevertheless  there  may  be  long  intervals 
between  such  attacks,  the  patient  in  the  meantime  continuing  in  fair 
health.  Thus  the  disease  may  linger  or  recur  for  years,  the  patient 
not  ill  enough  to  be  confined  to  the  house,  and  not  well  enough  to  stand 
hard  work  or  great  exposure.  Slowly,  by  ulceration  and  suppuration, 
the  lung-tissue  is  wasted  and  cavities  are  formed.  Before  there  are 
large  cavities  at  an  apex  the  base  of  the  same  lung  becomes  consoli- 
dated by  the  production  of  tuberculous  material,  and  before  one  lung  is 
extensively  diseased  the  apex  of  the  opposite  lung  is  attacked,  the  pro- 
cess being  repeated  in  it  if  the  patient  lives  long  enough.  Instead  of 
re-infection  from  an  old  focus,  new  infection  may  take  place,  giving  rise 
to  the  old  train  of  symptoms,  or  setting  up  more  acute  disease.  During 
this  time  the  patient  is  liable  to  an  attack  of  acute  pneumonia,  pleu- 
risy, bronchitis,  or  general  miliary  tuberculosis.  He  is  also  liable  to 
sudden  death  by  hemorrhage.  In  a  number  of  cases  the  intestines 
and  peritoneum  become  affected,  and  abdominal  pain  and  diarrhoea 
are  superadded  as  symptoms. 

As  a  rule,  the  patient  gradually  sinks.  The  later  stages  are  marked 
by  increasing  cough  and  dyspnoea,  which  are  very  distressing  and  pre- 
vent sleep.  Expectoration  is  more  copious,  purulent,  and  is  raised 
with  increasing  difficulty. 

The  appetite  is  poor  and  capricious,  or  anorexia  is  complete.  The 
heart  becomes  more  and  more  feeble,  the  fever  is  hectic  and  accompa- 
nied by  exhausting  night-sweats,  the  feet  and  limbs  swell,  and  acute 
cramp-like  pains  are  felt  in  the  legs,  probably  caused  by  thrombosis  of 
the  veins. 


DISEASES  OF  THE  LUNGS  AND  PLEURJS.  333 

Emaciation  is  extreme,  scarcely  anything  but  skin  and  bone  being 
left.  Death  occurs  from  perforation  of  an  intestinal  or  gastric  ulcer, 
from  hemorrhage,  or  more  commonly  from  exhaustion,  and  from 
asphyxia  caused  by  oedenia  of  the  lungs. 

The  physical  signs  depend  upon  the  lesions.  It  is  often  possible  to 
detect  all  stages  of  the  tubercular  process,  from  early  consolidation  to 
large  cavity,  in  the  same  patient.  The  signs  of  consolidation  have 
been  sufficiently  dwelt  upon.  When  softening  begins,  the  percussion- 
note  continues  dull  and  the  breathing  bronchial;  but  it  is  often  difficult 
to  make  out  the  quality  of  the  breath-sounds  because  they  are  feeble 
and  obscured  by  numerous  moist  crackling  rales  and  moist  subcrepi- 
tant  rales  from  disintegration  of  lung-tissue  and  bronchitis.  After 
the  patient  has  coughed  several  times  and  expectorated,  and  then  takes 
a  long  breath,  the  quality  of  the  breathing  becomes  perceptible.  As 
the  lung-tissue  is  further  softened  and  removed  by  expectoration  cavi- 
ties are  formed.  These,  if  large  enough  and  superficial,  give  a  tym- 
panitic note  on  percussion,  and,  if  there  is  a  communication  with  a 
bronchus,  a  cracked-pot  sound.  The  breath-sounds  are  hollow  and  the 
rales  are  bubbling  and  gurgling,  or  large  and  mucous. 

The  normal  vocal  resonance  is  replaced  by  bronchophony  and  pecto- 
riloquy. Tactile  fremitus  may  or  may  not  be  increased  (see  Cavi- 
ties.) 

But  if  the  walls  of  the  cavity  are  thick  from  indurated  tissue,  the 
percussion-note  will  be  dull  and  the  breathing  bronchial.  If  the  tissue 
composing  the  wall  is  less  thick  and  dense,  percussion  produces  a  wooden 
sort  of  resonance.  If  much  normal  lung- tissue  intervenes,  the  per- 
cussion-note will  be  clear. 

As  tuberculosis  of  the  lungs  progresses,  the  clavicles  and  ribs  become 
more  and  more  prominent  from  the  loss  of  fat,  and  local  flattening  of 
the  chest,  with  impaired  expansion,  marks  the  seat  of  the  disease. 

The  Diagnostic  Features.  The  striking  phenomena  of  tuber- 
culosis which  are  considered  in  the  diagnosis  are  emaciation,  anaemia, 
fever,  cough,  dyspnoea,  chest-pain,  hemorrhage,  the  expectoration,  and 
the  objective  symptoms.  Of  less  diagnostic  value,  but  important  as 
collateral  data,  are  the  aspect,  the  occurrence  of  vomiting  and  diar- 
rhoea, and  of  symptoms  of  secondary  tuberculosis  in  other  organs. 
Age  and  occupation  may,  to  a  certain  extent,  aid  in  the  diagnosis. 

Emaciation.  This  is  always  seen,  even  in  acute  forms  of  tubercu- 
losis. It  is  rapid  in  the  acute,  slow  and  progressive  in  the  chronic  forms. 
In  the  latter  there  may  be  a  temporary  improvement  in  this  respect. 
It  must  not  be  confounded  with  muscular  atrophy,  and  the  emaciation 
of  carcinoma,  diabetes,  anorexia  nervosa,  and  other  exhausting  diseases. 
Ancemia  is  always  pronounced.  It  may  be  associated  with  leucocytosis. 
The  reduction  of  red  cells  and  diminution  of  haemoglobin  are  marked. 
Fever.  This  symptom  is  always  present.  The  temperature  should  be 
taken  every  two  hours  for  a  time,  to  determine  accurately  the  degree 
and  course.  It  may  be  intermitting,  remitting,  or  continuous.  It  may 
be  intermitting  in  some  acute  forms,  the  morning  fall  reaching,  or  going 
below,  normal.  The  difference  between,  morning  and  evening  temper- 
ature may  not  be  more  than  a  degree.     In  the  acute  form  it  is  high  and 


334 


SPECIAL  DIAGNOSIS. 


continuous,  and  soon  may  be  attended  by  the  typhoid  state.  In  the 
more  chronic  cases  it  may  be  intermittent  at  first,  then  continuous,  and 
finally  intermittent  again.  In  the  later  stages  the  intermitting  fever 
is  due  to  a  mixed  infection,  or  saprsernia,  from  the  purulent  contents 
(staphylococcus  and  streptococcus  infection)  of  the  lung  cavities1  (see 
Fig.  61  and  Fig.  62).  The  intermittent  fever  of  the  early  stages  has 
frequently  been  mistaken  for  malaria  (see  Fever).      The  occurrence  of 


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Fig.  62. 


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— 

Intermitting  fever  of  tuberculosis. 

fever  in  a  patient  who  has  been  losing  flesh,  and  is  otherwise  in  poor 
health,  excludes  cancer  and  diabetes  and  other  afebrile  causes,  and 
points  strongly  to  tuberculosis.  It  must  not  be  forgotten  that  in  chronic 
tuberculosis  in  the  aged  the  temperature  may  not  rise  above  100° ;  often, 
indeed,  it  is  subnormal. 

1  Leyden  has  recently  pointed  out  that  intermitting  fever  is  part  of  the  tuberculous  process,  and 
not  a  s'trepto-  or  staphylococcus  infection  as  formerly  held,  because  pus  micro-organisms  are  not 
found  in  the  purulent  contents  of  cavities,  and  because  in  other  forms  of  tuberculosis,  as  em- 
pyema or  joint-disease,  they  are  notably  absent,  and  yet  such  form  of  fever  exists.— Deutsche 
-median.   Wochennchrift,  Sept.  14,  1891. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  335 

We  must  consider,  therefore,  that  fever,  the  cause  of  which  is  not 
obvious,  maybe  due  to  tuberculosis;  and  that  if,  when  such  probable 
causal  conditions  as  gastro-intestinal  catarrh  or  infectious  disorders 
(malaria)  and  suppurations  are  eliminated,  the  fever  still  persists,  then 
the  fever  is  probably  of  tuberculous  origin. 

Sweats.  Frequent  sweating  may  be  the  first  symptom  complained 
of  by  the  patient.  It  may  occur  with  the  tripod  of  symptoms  of  the 
intermitting  febrile  range — chill,  fever,  and  sweat.  It  would  be  likely 
to  occur  at  night  under  these  circumstances.  It  may  occur  at  any  time, 
however.  "  Night-sweats"  are  alarming  to  the  mind  of  the  laity,  and 
are  really  of  diagnostic  significance.  The  perspiration  awakens  the 
patient  at  night  because  it  is  so  profuse.  It  may  be  only  moderate, 
not  rousing  the  patient  until  morning.  It  may  be  general  or  local. 
Local  sweats  are  confined  to  the  head  and  neck.  Ancemia.  This 
quite  rapidly  becomes  marked.  It  is  recognized  by  the  color  of  the 
surface  and  by  an  examination  of  the  blood.  When  collateral  inflam- 
mation is  present,  leucocylosis  is  seen.  Cough.  Cough  is  one  of  the 
earliest  symptoms.  It  may  be  the  only  symptom  for  some  time.  It 
is  often  dry  and  hacking  at  first  and  may  continue  so  for  a  long  time. 
Later  it  is  accompanied  by  mucoid  and  then  muco-purulent  sputa, 
which  contain  the  characteristic  elements  (see  Sputum).  Dyspnoea  is 
almost  always  present.  The  degree  varies  with  the  association  of  fever. 
When  the  latter  is  present  dyspnoea  is  more  pronounced.  It  is  more 
pronounced  in  acute  cases.  In  miliary  tuberculosis  the  frequency  of 
respirations  that  attends  the  dyspnoea  is  out  of  all  proportion  to  the 
physical  signs.  In  this  form  cyanosis  is  more  marked.  In  chronic 
localized  phthisis  the  dypsnoea  may  only  occur  on  exertion,  after  eating, 
or  upon  excitement.  The  bloodless  lips  may  have  a  constant  bluish 
hue.  The  fingers  are  dusky  and  become  "  clubbed."  In  the  later 
stages  the  dyspnoea  is  constant  and  in  proportion  to  the  extent  of  involve- 
ment of  the  lungs  and  the  degree  of  fever.  Although  of  diagnostic 
significance  only  when  associated  with  other  symptoms,  it  is  most  dis- 
tressing, and  is  the  cause  of  constant  demand  for  relief. 

Chest-pain.  This  is  due  to  localized  pleurisy  or  to  myalgia.  The 
latter  may  be  seated  in  muscles  strained  by  coughing.  Pleuritic  pains 
may  occur  in  any  situation,  and  vary  in  position  from  time  to  time. 
They  may  be  due  to  extensive  inflammation  or  to  tuberculous  pleurisy. 
Constantly  recurring  and  unilateral  chest-pains,  with  or  without  signs 
of  pleurisy,  with  cough  and  emaciation,  are  significant  of  the  disorder 
under  consideration  (see  Pain). 

Hemorrhage.  This  symptom  is  alarming,  and,  in  the  large  majority 
of  cases,  due  to  pulmonary  tuberculosis.  It  may  mark  the  onset  of 
the  acute  disease,  and  continue  irregularly  throughout  its  course  or 
recur  several  times  before  the  advent  of  more  common  symptoms  of 
the  chronic  form.  It  may  occur  at  intervals  of  a  few  months  or  a 
year,  before  emaciation,  cough,  and  characteristic  expectoration  set  in, 
or  before  bacilli  arc  found  in  the  sputum.  Each  attack  is  attended  by 
fever,  usually,  and  followed  by  anaemia  and  prostration.  If  hemor- 
rhage of  the  lungs  (see  Symptoms)  occurs  in  a  young  adult  without 
cause  (as  aneurism  or  cardiac  disease,  etc.),  it   must  be   looked   upon 


336  SPECIAL  DIAGNOSIS. 

with  suspicion.  The  likelihood  of  tuberculosis  is  increased  if  the 
bleeding  occurs  in  a  patient  of  tuberculous  aspect,  in  whoni  a  family 
history  of  tuberculosis  is  found,  and  who  has  been  exposed  to  infection. 
In  the  aged  it  may  occur  from  a  localized  area  of  disease.  Hemorrhage 
is  also  common  in  the  late  stages  of  tuberculosis.  It  is  not  at  this 
period  of  diagnostic  value  as  to  the  primary  cause.  It  is  usually  due 
to  the  erosion  of  an  artery  in  a  cavity.  Hemorrhage  also  occurs  in 
tuberculosis  during  the  quiescent  period.  The  progress  of  the  disease  is 
arrested.  The  discharge  of  blood  is  accompanied  by  the  expectoration 
of  pulmonoliths,  calculi  formed  by  the  degeneration  of  caseous  areas. 

The  Sputum  (q.  v  ).  The  diagnosis  is  absolute  when  tubercle  bacilli 
are  found  in  the  expectoration.  Nummular  sputa  are  more  common  in 
phthisical  excavation.  The  sputum  is  discharged  in  tough  coin-shaped 
masses  which  sink  when  expectorated  into  a  vessel  containing  water. 
Fragments  of  lung-tissue  (yellow  elastic)  point  to  tuberculosis,  but 
are  possible  under  other  circumstances. 

The  Physical  Signs.  The  objective  signs  point  to  invasion  of  air- 
containing  structure  by  solid  material,  with  collapse  of  globules,  to 
consolidation,  and  to  cavity-formation,  and  to  the  secondary  occurrence 
of  pleurisy.  In  the  chronic  cases,  contraction,  impaired  movement, 
dulness  and  increased  resistance  from  thickened  pleura  may  override 
the  signs  of  consolidation.  No  one  physical  sign  is  of  diagnostic  sig- 
nificance. The  combination  of  signs,  and  the  orderly  procession  by 
which  they  advance  as  the  physical  conditions  progress,  are  the  most 
diagnostic.  Local  contraction  (flattening)  and  impaired  movement  at 
an  apex,  with  inspiratory  depression  above  the  clavicles,  with  sup- 
pressed breath-sounds  and  prolonged  expiration,  with  impaired  reso- 
nance, are  the  earliest  signs  of  tuberculosis. 

The  aspect  of  the  patient  is  always  suggestive,  and  is  an  aid  to  the 
recognition  of  the  condition.  The  tuberculous  or  phthisical  chest,  the 
long  neck  and  arms,  the  pale  fac°,  the  occasional  hectic  flush,  the 
clubbed  fingers,  the  emaciation  of  the  many  subjects  we  see  in  our 
infirmaries,  fix  in  our  minds  a  composite  picture  the  recognition  of 
which  in  individual  cases  goes  far  to  diagnosticate  the  insidious  disease. 
Vomiting  (see  Gastro-intestinal  Disease)  is  a  symptom  which  is  often 
present  in  the  early  stages  of  tuberculosis  of  the  lungs,  and  frequently 
masks  the  true  condition.  The  vomiting  may  lead  to  the  belief  that  a 
local  gastric  catarrh  or  diarrhoea  is  to  blame  for  the  general  symptoms. 
The  occurrence  of  fever  with  the  gastric  symptoms  should  lead  to  an 
examination  of  the  lungs. 

The  occurrence  of  diarrhoea  and  symptoms  of  tuberculosis  in  other 
organs  may  thoroughly  establish  the  diagnosis  in  tuberculosis  of  the 
lungs  with  otherwise  obscure  pulmonary  symptoms.  The  intestinal 
discharges  may  contain  tubercle  bacilli,  or  they  may  be  found  in  the 
urine,  in  joint-suppuration  or  glandular  enlargement. 

It  is  necessary  also  to  consider  carefully  the  general  conditions.  We 
inquire  the  age,  adolescence  and  early  adult  life  being  the  common 
periods  in  which  pulmonary  tuberculosis  develops.      The  occupation,1 

1  Several  undoubted  instances  are  recorded  in  which  hospital  residents  and  youn?  physicians 
working  in  laboratories  in  which  tuberculosis  is  studied,  or  constantly  examining  sputum,  have 
been  infected  in  the  course  of  their  studies. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  337 

the  history  of  exposure  to  the  disease,  the  history  of  predisposition  to 
tuberculosis  in  the  family,  the  history  of  previous,  now  arrested,  tuber- 
culosis, as  in  joint-disease,  or  glandular  tuberculosis  (scrofula),  arc 
data  deserving  special  consideration,  as  they  may  furnish  corroborative 
evidence  of  the  presence  of  the  disease. 

The  Diagnosis  is  Established  by  Finding  Tubercle  Bacilli  in  the  Spu- 
tum. Their  absence,  in  spite  of  the  most  careful  search,  is  against  the 
tuberculous  origin  of  the  disease. 

In  subsequent  chapters  the  differential  diagnosis  of  tuberculosis  and 
other  diseases  will  be  pointed  out.  It  must  not  be  forgotten  that  the 
disease  may  set  in  as  the  terminal  affection  in  many  diseases.  Thus, 
in  diabetes,  in  insanity,  in  chronic  cerebral  or  spinal  disease,  and  in 
other  affections,  tuberculosis  may  develop  insidiously,  and  fiually  cause 
death. 

It  must  be  distinguished  from  chronic  gastric  disorders,  and  particu- 
larly anorexia  nervosa.  It  must  not  be  confounded  with  malaria.  It 
must  be  distinguished  from  simple  anEemia,  the  cause  of  which  may  be 
recognized  with  difficulty.  It  must  be  distinguished  from  chrome 
bronchitis  with  bronchiectasis,  from  pulmonary  gangrene  and  carci- 
noma. Finally,  it  must  not  be  mistaken  for  cancer  of  the  oesophagus 
and  aneurism  of  the  aorta,  two  divergent  conditions  which  may  have 
pulmonary  symptoms  simulating  phthisis. 

Gangrene  of  the  Lung. 

Gangrene  is  a  rare  disease  of  the  lung,  and,  like  abscess,  always 
secondary.  It  may  be  produced  by  any  cause  which  so  obstructs  the 
circulation  that  a  portion  of  lung  dies  in  bulk.  The  gangrene  may  be 
circumscribed  or  diffused;  it  results  most  frequently  from  pneumonia, 
but  may  be  due  to  injury,  to  a  general  septic  condition,  or  to  embolism. 
It  is  rather  frequently  met  with  in  the  insane,  possibly  owing  to  par- 
ticles of  food  which  have  found  their  way  into  the  lung.  Aspiration 
broncho-pneumonia,  bronchiectatic  and  tuberculous  cavities,  sometimes 
lead  to  gangrene.  Gangrene  in  the  lung,  as  elsewhere,  occurs  in  dia- 
betes. 

Symptoms.  When  it  occurs  in  the  insane,  or  is  of  embolic  origin,  it 
may  remain  latent,  and  in  septicaemia  it  may  be  overlooked  on  account 
of  the  general  symptoms.  In  well-marked  cases,  however,  the  symp- 
toms are  characteristic.  Symptoms  and  physical  signs  of  pulmonary 
dis<  sase  precede  the  specific  symptoms  of  gangrene.  With  the  onset  of 
a  moderate  fever  haemoptysis  may  occur  at  once  or  be  preceded  by  the 
expectoration  of  a  brownish,  purulent  sputa  having  a  most  intense  and 
persistent  gangrenous  odor.  It  contains  fragments  of  lung-tissue, 
altered  blood,  and  putrid  debris  (see  Sputum).  It  separates  into  the 
three  characteristic  layers  in  a  conical  glass.  The  fcetor  of  the  breath 
and  sputum  is  diagnostic. 

The  disease  usually  occupies  the  lower  or  middle  lobe  of  the  lung. 
The  physical  signs  are  those  of  cavity.  The  disease  could  with  diffi- 
culty be  distinguished  from  abscess  were  it  not  for  the  characteristic 
sputum,  though  in  gangrene  there  is  greater  tendency  to  a  general 
septic  condition,  with  profuse  sweats  and  collapse. 

22 


338  SPECIAL  DIAGNOSIS. 

Abscess  of  the  Lung. 

Abscess  of  the  lung  may  originate  in  causes  outside  the  lung,  or  in 
causes  within  the  lung.  To  the  former  class  belong  those  produced  by 
suppurating  bronchial  glands,  abscess  of  the  mediastinum  opening  into 
the  lung,  cancer  of  the  oesophagus  with  ulceration,  and  abscess  of  the 
liver,  suppurating  hydatid  cyst,  or  sub-diaphragmatic  abscess  in  gen- 
eral, bursting  into  the  lung.  Intra-pulmonary  causes  are  tubercle, 
septic  emboli,  in  which  case  the  abscesses  are  multiple  and  subpleural, 
and  pneumonia.  In  the  aspiration  form  of  lobular  pneumonia  abscesses 
occur.  Rarer  causes  are  the  presence  of  tumors  and  obstruction  of  the 
bronchi. 

Abscess  of  the  lung  is  therefore  always  secondary.  Its  diagnosis 
depends  upon  the  demonstration  of  a  consolidation  in  which  a  cavity 
subsequently  forms,  taken  in  connection  with  the  history  pointing  to  a 
cause.  The  sputa  are  copious,  purulent,  often  odorless,  sometimes 
offensive,  but  always  without  the  foetor  of  gangrene.  They  contain 
elastic  fibre,  but  no  bacilli  except  in  tuberculous  cases  (see  Sputum). 
In  embolic  abscess  the  signs  of  pleural  friction  can  only  be  detected 
at  times.  Of  course,  the  constitutional  symptoms  of  suppuration  are 
present. 

Collapse  of  the  Luxg. 

Collapse  of  the  lung  is  a  condition  produced  by  exhaustion  of  air 
from  the  air-vesicles.  It  may  affect  alveoli  here  and  there,  or  a  large 
section  of  the  lung.  Formerly  such  collapse  was  invariably  looked 
upon  as  pneumonia,  until  Legendre  and  Bailly  proved  by  forcible  infla- 
tion that  the  air-vesicles  had  simply  collapsed  from  absence  of  air. 
Collapse  occurs  most  frequently  in  the  course  of  bronchitis  and  in  cases 
with  feeble  respiratory  power.  The  bronchial  twigs  supplying  certain 
air-vesicles,  or  tubes  supplying  sections  of  lung,  become  occluded  to 
such  a  degree  that  no  air  can  enter.  The  air  already  contained  in  the 
vesicles  then  becomes  exhausted  gradually  until  the  vesicles  are  com- 
pletely airless.  The  vesicles  or  sections  of  lung  involved  then  return 
to  their  foetal  coudition.  When  the  collapse  is  congenital  the  term 
atelectasis  is  preferable.  Anything  which  induces  great  muscular  weak- 
ness predisposes  to  collapse  of  the  lung;  hence  in  the  aged  and  feeble, 
in  wasting  diseases,  and  in  low  febrile  diseases  of  long  standing,  col- 
lapse is  very  apt  to  occur.  But  bronchitis  is  the  most  frequent  and 
direct  cause.  The  secretions  which  are  poured  out,  and  the  swelling 
of  the  mucous  membrane,  occlude  the  tubes,  and  if  the  patient  have 
not  strength  enough  to  expel  the  secretions,  and  by  forced  inspiration 
expand  the  collapsing  vesicles,  collapse  ensues. 

Diagnosis.  The  diagnosis  of  the  condition  in  life  is  difficult.  The 
area  of  collapse,  being  airless,  is,  of  course,  dull  on  percussion.  The 
respiratory  murmur  is  more  likely  to  be  faint  or  absent  than  to  be  in- 
creased in  intensity  or  approach  the  bronchial.  Nevertheless  there  is 
sometimes  heard  a  faint  broncho-vesicular  expiration. 

AVhen  oedema  is  superadded  to  collapse,  moist  crepitant  rales  are 
heard,  difficult  if  not  impossible  to  distinguish  from  those  of  pneumo- 


DISEASES  OF  THE  LUNGS  AND  PLEUR2E.  339 

nia.  Respiration  is  embarrassed,  and  is  accompanied  by  sucking-in  of 
the  lower  part  of  the  chest  in  inspiration.  Sometimes  the  plug  of 
mucus  which  occludes  the  tubes  becomes  dislodged  while  the  physician 
is  auscultating,  and  then  the  respiratory  murmur  will  be  heard  accom- 
panied by  a  succession  of  crepitant  rales,  which  disappear  after  a  few 
inspirations.  The  dull  areas,  as  a  rule,  are  less  persistent  than  those 
of  pneumonia;  thus  it  may  be  found  at  successive  examinations  that 
one  area  has  cleared  up  and  another  has  become  dull.  Stress  is  laid 
by  some  writers  upon  the  signs  of  emphysema  surrounding  collapsed 
areas.  But  this  does  not  give  assistance  in  the  cases  in  which  most  help 
is  required — cases  in  which  there  is  diffuse  bronchitis  with  more  or  less 
oedema. 

Subjective  symptoms  are  those  of  dyspnoea  and  insufficient  oxygena- 
tion of  the  blood.  If  these  are  developed  suddenly,  and  are  accom- 
panied by  the  appearance  of  dull  areas  in  the  lung  without  bronchial 
breathing,  the  diagnosis  is  tolerably  certain;  but  when  scattered  lob- 
ules only  are  involved,  the  physical  signs  of  collapse  are  absent,  and 
its  existence  must  be  a  matter  of  inference. 

From  lobar  pneumonia  the  diagnosis  is  easily  made  by  the  difference 
in  the  physical  signs,  and  by  the  absence  in  pulmonary  collapse  of 
inflammatory  symptoms,  by  the  lower  temperature,  and  the  difference 
in  onset. 

The  diagnosis  from  broncho-pneumonia,  or  catarrhal  pneumonia,  is 
beset  with  greater  difficulties.  But  here  also  the  lower  temperature, 
and  the  fact  that  the  physical  signs  and  the  location  of  the  dull  areas 
are  subject  to  rapid  changes,  are  of  aid  in  diagnosis. 

Cancer  and  Other  New  Growths  of  the  Lung. 

The  new  growths  may  be  primary  or  secondary.  The  latter  are  most 
common.  Of  primary  cancer,  the  epithelioma  is  most  common ;  enceph- 
aloid  and  scirrhus  come  next.  Sarcoma  is  sometimes  primary.  Sec- 
ondary new  growths  succeed  disease  in  the  abdominal  organs,  the 
genito-urinary  tract,  the  bones,  the  breast,  and  the  eye. 

Symptoms.  The  general  symptoms  of  malignant  growths  accom- 
pany the  thoracic  symptoms.  Chest-pain,  dyspnoea,  cough,  and  a 
peculiar  expectoration  belong  to  the  latter.  The  pain  is  due  to  asso- 
ciate  pleurisy;  the  dyspnoea  is  paroxysmal.  (See  dyspnoea  from  pres- 
sure on  bronchi.)  The  expectoration  is  dark,  like  prune-juice.  Signs 
of  intra-thoracic  pressure  are  seen.  The  external  thoracic  veins  are 
enlarged.  The  face  and  arms  may  be  cyanosed,  or  one  arm  only  may 
be  affected.  The  heart  may  be  dislocated,  the  trachea  changed  in  its 
course;  compression  of  trachea  and  bronchus  causes  dyspnoea. 

Physical  Signs.  In  primary  cancer  the  affection  is  unilateral;  in 
secondary  forms,  bilateral.  The  physical  signs  are  those  of  pleura] 
effusion  or  of  local  consolidation.  The  consolidation  may  be  massive 
and  not  partake  of  the  shape  of  a  lobe.  Often  signs  of  effusion  and 
consolidation  arc  combined  (enlargement,  immobility,  absent  fremitus, 
but  bronchial  breathing).  In  the  secondary  forms  the  disease  is  bilat- 
eral.    The  signs  are  mixed.     They  indicate  diminished  air  in  the  lung 


340  SPECIAL  DIAGNOSIS. 

structure.  Care  must  be  taken  not  to  overlook  the  pleural  effusion 
which  accompanies  the  process,  the  removal  of  which  gives  temporary 
relief.  In  both  forms  external  lymphatic  glands,  particularly  the  cer- 
vical, may  be  enlarged. 

Diagnosis.  The  diagnosis  is  based  upon — 1,  the  age  (after  forty); 
2,  the  occurrence  of  emaciation;  3,  the  duration  of  the  disease,  often 
rapid,  rarely  beyond  eight  months;  4,  the  presence  of  primary  disease 
elsewhere;  5,  the  presence  of  moderate  fever;  6,  the  sigus  of  intra- 
thoracic pressure;  7,  the  involvement  of  lymphatic  glands;  8,  the 
occurrence  of  irregular  areas  of  consolidation  and  of  pleural  effusion, 
alone  or  combined;  9,  the  characteristic  expectoration;  10,  dyspnoea 
due  to  pressure  on  the  bronchus  or  trachea;  11,  the  absence  of  bacilli 
from  the  sputum. 

An  effusion  can  often  be  recognized  only  after  puncture.  Hamio- 
thorax  is  not  necessarily  present. 

Hydatid  Disease  of  the  Lungs. 

The  lungs  are  affected  in  about  11  per  cent,  of  the  cases  of  hydatid 
disease.  The  symptoms,  according  to  Wilson  Fox,  consist  of  dyspnoea, 
pain  in  the  chest,  cough,  occasional  haemoptysis,  and  sometimes  the 
expectoration  of  hydatids,  the  sputa  being  otherwise  bronchitic,  or 
presenting  the  characteristics  of  pneumonia  or  gangrene,  when  these 
complications  are  present.  Gradually  weakness  increases,  sometimes 
with  pyrexia,  which,  when  combined  with  emaciation,  may  impart  to 
the  case  a  considerable  resemblance  to  phthisis;  pressure-symptoms 
occasionally  occur,  and  the  physical  signs  are  either  of  consolidation  of 
the  lung  or  of  pleural  effusion,  together  with  certain  peculiarities  de- 
pending on  the  size  and  site  of  the  tumor.  Graham  states  that  they 
are  more  frequent  in  the  right  lung  and  more  common  at  the  base,  caus- 
ing marked  bulging  of  the  thoracic  wall.  The  physical  signs  are  those 
of  pleural  effusion  with  localization  of  the  fluid  to  a  definite  area,  and 
hence  not  related  to  the  shape  of  the  pleural  cavity.  The  breathing 
may  be  tubular;  there  is  condensed  lung  between  the  hydatid  and  the 
thoracic  wall.  The  symptoms  present — cough,  dyspnoea,  anaemia,  ema- 
ciation, and  clubbing  of  fingers — too  often  lead  to  the  diagnosis  of 
phthisis.  Haemoptysis  occurs  in  many  cases.  The.  temperature  is 
normal — an  important  point  in  diagnosis.  If  the  cyst  ruptures,  the 
sputum  is  diagnostic.  Complications  often  mark  the  diagnosis.  It 
must  be  distinguished  from  pleurisy,  localized  empyema,  pulmonary 
abscess,  phthisis,  and  mediastinal  tumors. 

Diseases  of  the  Pleura. 

The  large  lymph-structures  which  cover  the  lung  and  line  the  inside 
of  the  thorax  are  often  the  seat  of  disease.  It  is  usually  of  an  inflam- 
matory nature.  Hence,  pleurisy,  or  pleuritis,  is  the  most  common 
affection  of  the  pleura,  It  may  be,  as  to  distribution,  bilateral  or 
unilateral;  as  to  extent,  local  or  general;  as  to  the  nature  of  the  inflam- 
mation, plastic,  serous,  or  purulent.  The  inflammation  may  be  acute 
or  chronic.     It  is  rarely  primary.     It  arises  in  the  course  of  general 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  341 

diseases,  or  is  the  result  of  the  extension  of  inflammation,  chiefly  of 
an  infectious  nature,  from  neighboring  structures. 

1.  Disease  of  the  ribs  or  vertebras,  diseases  of  the  mediastinum,  of 
the  aorta,  oesophagus,  and  especially  of  the  lung,  give  rise  to  various 
forms  of  pleurisy,  depending  upon  the  nature  of  the  primary  affection. 

2.  Disease  below  the  diaphragm.  Abscess  of  the  liver;  perforative 
inflammation  of  other  viscera  adjacent  to  the  diaphragm;  abscess  of 
the  spleen  or  pancreas;  pus  in  the  pelvis  or  about  the  appenilix,  may 
give  rise  to  purulent  pleurisy  by  burrowing  of  the  pus  or  infection 
through  the  lymph-channels. 

3.  Disease  of  the  lungs.  In  the  large  majority  of  cases  pleurisy  in 
some  form  occurs  in  the  course  of  pulmonary  disease.  In  all  surface 
inflammations  of  the  lungs,  there  is  associate  pleurisy.  It  is  seen  in 
pneumonia,  in  tuberculosis,  in  gangrene,  and  in  abscess. 

Pleurisy  may  be  simple  or  purulent.  Empyema  is  always  due  to 
infection  from  the  exterior,  as  the  ribs;  from  the  lungs  (pneumonia); 
suppuration  below  the  diaphragm;  or  to  general  infective  processes,  as 
septicaemia,  pyaemia,  and  tuberculosis. 

The  general  diseases  in  the  course  of  which  pleuritis  arises  are  usually 
infective,  or  of  such  nature  as  to  cause  irritating  products  to  circulate 
in  the  blood.  Of  the  former,  the  most  common  is  tuberculosis;  the 
next  most  common  are  septicemia  and  scarlatina;  while  to  the  latter 
class  belong  Bright' s  disease,  gout,  diabetes,  rheumatism,  and  scurvy. 
Purulent  pleurisy  is  more  common  in  children  than  in  adults;  in  males 
than  in  females;  and  more  common  in  tuberculous  pleurisy  and  pyemia 
than  in  rheumatism  and  Bright' s  disease. 

Acute  Pleurisy. 

Acute  pleurisy  may  be  primary,  or  may  be  secondary  to  disease  of 
the  lung,  or  be  part  of  a  general  infection.  Three  stages  in  the  morbid 
process  usually  occur,  although  it  may  be  arrested  in  the  first  stage. 

Symptoms  of  the  First  Stage.  Dry  Pleurisy.  The  onset  of 
the  disease  is  usually  abrupt,  and  is  marked  by  fever,  which  may  or 
may  not  be  preceded  by  chill,  and  is  followed  by  pain  in  the  side,  dysp- 
ncea,  and  cough.  The  pain  is  sharp,  stabbing,  or  tearing  in  character, 
and  is  usually,  but  not  always,  referred  to  the  seat  of  pleurisy.  This 
is  most  frequently  on  a  level  with  the  nipple,  or  a  little  below  this,  and 
oftener  anteriorly  or  in  the  axilla  than  posteriorly.  The  pain  is  caused 
by  the  rubbing  together  of  the  inflamed  surfaces  of  the  pleura,  and 
hence  is  excited  by  respiration  and  cough.  For  this  reason  the  patient 
is  inclined  to  restrict  the  motion  of  the  affected  side  as  much  as  possi- 
ble; he  does  this  by  leaning  over  toward  that  side  and  by  pressing  his 
elbow  in  against  the  chest-wall.  Pain  is  usually  the  first  symptom  no- 
ticed by  the  patient.    The  cough  is  dry  and  painful.    Fever  is  moderate. 

The  physical  signs  in  primary  cases  are  a  friction-sound  heard  on 
inspiration  and  expiration.  This  friction-sound  may  be  a  nesl  of  line, 
dry,  crepitant  rales,  which  are  very  superficial,  and  appear  to  he  just 
under  the  ear;  or  a  coarse  rubbing  sound,  heard  over  a  larger  surface, 
and  resembling  a  bronchial  rhonch  us,  from  which  ii  can  he  distinguished 


342  SPECIAL  DIAGNOSIS. 

by  its  persisting  after  the  patient  has  coughed.  The  lungs  themselves 
present  nothing  abnormal. 

If  the  inflamed  surfaces  become  glued  together  by  plastic  lymph, 
recovery  usually  occurs  very  soon,  though  pain  often  persists  for  a  long 
time  in  lessened  degree,  and  the  pleurisy  is  liable  to  be  re-lighted. 

Symptoms  of  Second  Stage,  or  Stage  of  Effusion.  If  effu- 
sion takes  place,  the  two  layers  of  the  pleura  become  separated;  hence 
pain  and  friction-sound  cease,  and  physical  exploration  shows  that  a 
collection  of  fluid  intervenes  between  the  chest-wall  and  the  lung.  The 
physical  signs  of  this  stage  are  (1)  enlargement  of  the  affected  side, 
increase  in  semi-circumference,  with  fulness  of  interspaces;  (2)  diminu- 
tion of  movement;  (3)  absence  of  vocal  fremitus  and  resonance;  (4) 
dulness  or  flatness  (deadness)  on  percussion,  with  great  increase  in  the 
resistance  to  the  pleximeter  finger;  (5)  absent  or  greatly  diminished 
respiratory  murmur;  (6)  displacement  of  organs. 

The  dead  percussion-note  being  caused  by  fluid,  it  follows  that  its 
upper  level  will  change  with  the  position  of  the  patient  if  the  fluid  is 
free.  If  the  upper  level  is  at  the  third  interspace  when  the  patient  is 
sitting  up,  it  wdl  fall  to  the  fourth  or  lower  when  he  is  lying  down. 
This  change  of  level  cannot  be  appreciated  when  the  effusion  is  very 
large.  Moreover,  above  the  line  of  dulness  the  percussion-note  is 
hyper-resonant  or  tympanitic — Skoda' s  resonance.  Toward  the  spine 
on  the  affected  side  there  may  be  partial  resonance  and  bronchial  breath- 
ing, because  here  the  lung  is  compressed  against  the  vertebrae.  In 
large  effusions  the  tympanitic  resonance  in  the  second  interspace  does 
not  change  when  the  mouth  is  opened,  that  is,  "  Williams'  tracheal 
tone"  can  often  be  elicited.  The  upper  limit  of  dulness  in  large 
pleural  effusions  is  higher  at  the  spine  and  slopes  downward,  and  is 
lowest  in  front.  This  parabolic  line  is  only  obtained  when  the  patient 
is  in  the  erect  posture.  In  moderate  effusions  the  line  of  dulness  is 
lowest  near  the  spinal  column,  rises  in  the  middle  of  the  scapula  and 
slopes  downward,  assuming  the  shape  of  the  letter  S  as  it  passes  toward 
the  front  (Garland).  The  patient  should  take  deep  breaths  before  the 
percussion  is  performed.  At  the  left  base  in  front  the  semilunar  space 
is  obliterated,  dulness  continuing  to  the  margin  of  the  ribs.  In  small 
effusions  the  dulness  may  be  limited  by  the  posterior  axillary  hue, 
resonance  being  present  in  the  lateral  and  anterior  regions. 

On  auscultation  below  the  upper  level  of  the  effusion  posteriorly  the 
voice  frequently  has  a  metallic  quality  resembling  the  bleating  of  a 
goat — oec/ophony.  It  occurs  usually  when  the  effusion  is  moderate,  and 
may  be  heard  only  over  a  limited  area.  It  is  commonly  heard  at  or 
above  the  angle  of  the  scapula.  Bronchophony  may  be  heard,  when 
tubular  breathing  is  present. 

While  the  respiratory  murmur  is,  as  a  rule,  absent,  breath-sounds 
may  be  heard,  and  are  then  weak  and  distant,  or  bronchial.  In  such 
cases  there  may  or  may  not  be  adhesions.  Bronchial  breathing  may  be 
present  along  the  spine  in  small  effusions,  and  in  large  effusions  in  the 
interscapular  region.  Bronchial  breathing,  tubular  in  character,  is 
said  to  be  almost  constant  in  children.  It  may  also  occur  when  pneu- 
monia coexists.   In  one  of  my  cases,  in  my  ward,  the  signs  were  like  those 


DISEASES  OF  THE  LUNGS  AXI)  PLEURAE. 


343 


of  a  large  cavity  at  the  right  base,  but  the  immobility,  absent  fremitus, 
the  enlargement,  and  the  exploratory  puncture  disproved  its  preseuce. 

At  the  level  of  the  fluid  a  friction-sound  may  persist.  Above  the 
level  of  fluid  anteriorly  the  breath-sound  may  be  bronchial  or  broncho- 
vesicular,  associated  sometimes  with  fine  rales,  due  to  compression  and 
slight  oedema. 

Displacement  of  Organs.  If  the  effusion  is  on  the  left  side,  the  medi- 
astinum and  heart  become  displaced  to  the  right,  and  the  apex-beat 
may  be  found  in  the  epigastrium,  or  even  to  the  right  of  it.  The 
occurrence  of  displacement  of  the  heart  must  also  be  judged  by  the 
position  of  maximum  intensity  of  the  heart-sound,  as  the  heart  may  be 
behind  the  sternum.  At  the  same  time  the  semilunar  space  (Traube'  s 
line)  is  lower  than  usual  or  entirely  effaced.  On  the  left  side  inaction 
of  the  diaphragm  may  be  observed,  and  the  tissues  at  the  costal  margin 
fall  in  with  each  inspiration  If  the  effusion  is  on  the  right  side,  the 
diaphragm,  and  with  it  the  liver,  is  depressed,  and  the  mediastinal  con- 
tents are  moved  to  the  left. 

Fig.  63. 


Pleurisy  with  effusion.    Recovery.    (Two  days  omitted.; 

The  subjective  symptoms  during  this  stage  are  slight  or  moderate 
fever,  sometimes  intermittent  in  character,  with  recurring  chills;  con- 
siderable dyspnoea,  occasionally  amounting  to  orthopnoea  when  the 
effusion  is  very  extensive;  and  dry  cough,  which  adds  greatly  to  the 
dyspnoea.  There  is  frequently  some  evidence  of  insufficient  oxygena- 
tion of  the  blood;  when  this  amounts  to  cyanosis,  the  condition  is  one 
of  great  danger.  The  urine  presents  changes  in  amount.  In  advancing 
effusion  the  amount  lessens  very  much;  it  increases  in  amount  with 
the  decline  of  the  fluid.  Pleurisy  may  be  complicated  with  bronchitis, 
pneumonia,  and  pericarditis. 

Empyema.  The  above-mentioned  physical  signs  apply  chiefly  to 
serous  effusions.  They  are  also  present  in  effusions  of  pus.  Other 
physical  phenomena,  however,  and  different  general  symptoms  distin- 
guish the  two  kinds  of  effusions,  although  it  must  be  confessed  that  aspi- 
ration must  often  be  resorted  to  before  a  positive  diagnosis  can  be  made. 


344 


SPECIAL  DIAGNOSIS. 


The  physical  signs  of  empyema  are  the  same  as  those  of  other  effu- 
sions within  the  pleura.  In  addition,  especially  in  children,  local 
oedema  of  the  chest- wall  may  be  found.  Another  sign  was  pointed 
out  by  Bacelli,  and  is  held  by  others  to  be  of  diagnostic  significance. 
In  purulent  effusions  the  fremitus  produced  by  the  whispering  voice  is 
not  transmitted  to  the  hand  laid  over  the  effusion,  whereas  in  serous 
effusions  such  vibrations  are  transmitted.  In  loculated  empyema  the 
diagnosis  is  very  difficult.  In  one  of  my  cases  dulness  continuous 
with  that  of  the  heart  extended  to  the  second  rib  and  laterally  to  the 
post-axillary  line.  The  dulness  occupied  three  interspaces.  Additional 
physical  signs  were  immobility,  prominence  of  interspaces,  localized 
above  the  heart,  absent  fremitus  and  resonance.  There  were  no 
breath- sounds,  but  an  abuudance  of  rales,  apparently  very  superficial. 
The  rales  complicated  the  physical  signs.  Martin  operated  for  me  and 
removed  two  ounces  of  pus  from  a  small  abscess  above  the  heart  and 
between  the  lobes. 

In  empyema  a  local  area  may  become  more  prominent  and  the  surface 
assume  an  inflammatory  appearance.  It  is  an  indication  of  discharge 
of  the  abscess  through  the  chest-wall.  It  is  usually  found  in  the  fifth 
interspace  in  front,  or  below  the  angle  of  the  scapula  behind — empy- 
ema necessitatis.  (For  a  microscopical  and  chemical  description  of  the 
"  Effusion  within  the  Pleural  Sac,"  and  of  the  morphological  elements 
of  the  purulent  effusions,  see  Part  I.,  Chapter  V.) 


Fig.  64. 


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Empyema  following  pneumonia.    (Fever  absent  from  seventh  to  fourteenth  day.) 


The  general  symptoms  are  more  marked  in  empyema  than  in  simple 
serous  effusion.  The  temperature  is  higher  from  the  onset.  It  soon 
becomes  intermittent  or  remittent.  Chills  or  chilliness  may  attend  the 
beginning  of  each  febrile  paroxysm,  and  sweats  occur,  with  the  daily 
fall  of  temperature,  or  at  irregular  periods  during  the  twenty-four 
hours.      The  heart's  action  is  more  rapid  and  the  pulse  more  feeble, 


DISEASES  OF  THE  LUNGS  AND  PLEURjE.  345 

soon  becoming  dicrotic.  Examination  of  the  urine  may  aid  in  the  dis- 
tinction of  the  two  forms  of  the  effusion.  Albumosuria  occurs  in  puru- 
lent pleurisy.  It  must  be  remembered  that  albumosuria  occurs  in 
suppuration  from  other  causes.  Thus,  in  phthisis  with  suppuration  of 
a  cavity  pleural  effusion  may  develop.  The  albumosuria  that  attends 
the  primary  process  must  not  be  mistaken  for  that  which  occurs  in 
empyema.  Indican  is  also  present  in  excess  in  the  urine  in  suppura- 
tions. Before  a  decisive  conclusion  is  arrived  at,  two  or  more  exam- 
inations of  the  urine  should  be  made.  Examination  of  the  blood  may 
aid  in  arriving  at  a  conclusion.  In  purulent  effusion  there  is  usually 
leucocytosis. 

Notwithstanding  the  positive  physical  signs  of  effusion  the  character 
of  the  effusion  may  not  be  recognized  until  perforation  into  the  bron- 
chus has  taken  place.  The  peculiar  character  of  the  expectoration 
that  attends  this  accident  is  described  in  the  section  on  Sputum. 

Hydrothorax.  This  is  an  accumulation  resulting  from  a  transu- 
dation. (For  character  of  the  fluid,  see  Chapter  V.)  It  occurs  in 
the  course  of  diseases  which  produce  anasarca,  as  failing  organic  heart 
disease,  chronic  Bright' s  disease,  and  debilitating  diseases,  as  scurvy. 
Locally  it  may  attend  carcinoma  of  the  pleura  or  obstructive  disease  of 
vessels  within  the  mediastinum. 

The  physical  signs  of  hydrothorax  are  those  of  effusion  in  acute 
pleurisy.  The  general  symptoms  belong  to  the  primary  disorder. 
Dyspnoea  may  develop  gradually  and  even  amount  to  orthopnea.  It 
is  distinguished  from  inflammatory  effusions  by  the  character  of  the 
fluid,  by  the  absence  of  the  general  symptoms  of  inflammation,  by  its 
insidious  development,  and  by  its  bilateral  distribution. 

Hemothorax.  The  transudation  of  blood  into  the  cavity  of  the 
pleura  occurs  rarely  from  the  rupture  of  an  aneurism  into  the  sac. 
The  fluid  is  then  pure  blood.  Serous  effusions  in  which  a  large  amount 
of  blood  is  found  point  to  primary  carcinoma  of  the  pleura,  or  to 
tuberculous  disease.  Both  specific  processes  of  this  serous  membrane 
may  occur,  however,  without  the  transudation  of  sero-bloody  fluid. 

Thickened  Pleura.  Chronic  inflammation,  with  thickening  of  the 
pleura  from  excessive  development  of  connective  tissue,  occurs  in  tuber- 
culosis and  in  cases  of  combined  pleuritis  and  peritonitis.  The  thicken- 
ing of  the  pleura  is  usually  more  marked  at  the  base.  The  physical 
signs  are  pronounced  and  are  those  of  effusion  but  without  enlarge- 
ment of  the  chest.  There  are  marked  contraction  and  diminution  in 
movement  of  the  affected  side.  The  fremitus  is  absent.  There  is 
dulness  on  percussion,  or  even  flatness.  The  breath-sounds  arc  distant 
or  are  absent  entirely.  Along  the  vertebra?,  especially  opposite  the 
angle  of  the  scapula,  bronchial  breathing  may  be  heard.  The  sub- 
jective symptoms  of  cough  and  dyspnoea  are  present.  The  degree  of 
COUgh  depends  upon  the  condition  of  the  lung.  If  there  is  bronchitis 
or  tuberculosis,  the  cough  is  excessive.  The  amount  of  dyspnoea  depends 
upon  the  degree  of  compression  of  the  lung  by  the  thickened  pleura. 

Tuberculous  Pleurisy.1     The  affection  may  be  acute  or  chronic. 

1  See  Xotes  on  Tuberculous  Pleurisy.  Musser,  American  Climatological  Association,  ls'.i:;. 


346  SPECIAL  DIAGNOSIS. 

It  may  occur  primarily,  be  a  part  of  general  tuberculous  infection,  or 
occur  secondarily  to  disease  of  the  lungs.  It  may  give  rise  to  all 
forms  of  the  inflammatory  process  :  First,  dry'  pleurisy;  second,  pleu- 
risy with  effusion;  third,  pleurisy  with  great  thickening.  Often  the 
distinction  between  tuberculous  pleurisy  and  pleurisy  due  to  other 
causes  cannot  be  determined  positively.  If  it  is  associated  with  tuber- 
culosis in  other  organs,  or  the  patient  is  of  tuberculous  habit  and 
exposed  to  infection,  or  if  there  has  been  a  history  of  previous  tuber- 
culosis, the  pleuritic  infection  is  probably  of  tuberculous  origin.  If 
the  affection  is  bilateral  and  associated  with  peritoneal  inflammation, 
and  at  the  same  time  no  other  cause  exists  for  serous  membrane  inflam- 
mation, the  probability  of  its  tuberculous  origin  is  very  strong. 

Pulsating  Pleural  Effusion.  Wilson  has  made  the  most  recent 
studies  of  this  rare  affection.  The  effusion  within  the  pleura  pulsates 
synchronously  with  the  ventricular  systole  ;  the  pulsation  is  detected 
usually  by  inspection  and  palpation.  In  some  instances  its  presence 
is  only  determined  by  palpation.  It  may  be  confined  to  two  or  three 
interspaces,  or  occupy  the  anterior  aspect  of  the  thorax  and  the  axil- 
lary region  on  the  left  side.  Earely  the  pulsation  is  behind.  It  is 
usually  situated  on  the  left  side.  The  original  effusion  is  purulent  in 
the  large  majority  of  cases.  The  physical  signs  and  general  symp- 
toms oi  empyema  are  present.  Nevertheless  the  disease  simulates 
aneurism  of  the  aorta.  The  latter  affection,  however,  is  accompanied 
by  vascular  symptoms  and  physical  signs  in  the  course  of  the  aorta. 
Pulsating  empyema  is  distinct  in  movement  from  the  pulsation  of  the 
aorta  and  occupies  a  different  anatomical  site. 

Diaphragmatic  Pleurisy.  In  diaphragmatic  pleurisy  there  is 
intense  pain  in  the  epigastrium.  Gueneau  de  Mussy1  regards  a  pain 
along  the  tenth  rib,  extending  from  the  anterior  extremity  to  the  ster- 
num and  xiphoid  cartilage,  as  pathognomonic.  Other  symptoms  are 
nausea,  vomiting,  and  hiccough.  The  dyspnoea  often  amounts  to  orthop- 
noea,  or  the  patient  sits  stooping  forward.  The  anxiety  of  the  patient 
is  very  great.  The  fever  is  usually  higher  than  in  ordinary  pleurisy, 
and  there  may  be  delirium.  Effusion  may  lessen  the  pain.  Peritonitis 
may  occur  at  the  same  time,  or  be  secondary  to  the  pleurisy. 

Diagnostic  Features.  The  special  features  of  diagnostic  impor- 
tance that  are  observed  in  the  course  of  pleurisy  are  the  pain,  the  dysp- 
noea, the  cough,  the  fever,  the  physical  signs  of  effusion  within  the 
pleura,  and  the  results  of  exploratory  puncture.  Pain :  The  pain  is 
short,  sharp,  lancinating,  and  is  usually  recognized  quite  readily  by  its 
character  and  location.  It  must  be  distinguished  from  the  pain  due  to 
pleurodynia  and  intercostal  neuralgia.  The  pain  of  pleurisy  is  associ- 
ated with  cough  and  is  increased  by  breathing.  It  causes  diminution 
of  movement  of  the  affected  side.  The  patient  is  compelled  to  sit  up 
in  bed,  or  lie  on  the  side  which  is  the  seat  of  pain.  Cough  :  In  the 
first  stage  the  cough  is  short,  suppressed,  dry,  and  painful.  It  is  con- 
stant. In  the  second  stage  it  changes  in  character.  There  is  no  pain, 
there  is  no  expectoration.     It  is  frequent  and  irritating  and  of  a  pecu- 

1  Arch.  gen.  de  Med.,  1853,  vol.  xi.    Quoted  by  Fox. 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  347 

liar  sound  which  is  difficult  to  describe,  and  yet,  when  once  heard,  is 
most  suggestive  in  subsequent  cases.  It  is  short  and  lacks  resonant 
quality,  as  if  the  fluid  in  the  chest  stopped  the  sound-waves.  Dysp- 
noea in  the  first  stage  is  due  to  pain,  in  the  second  stage  to  the  large 
effusion  which  encroaches  upon  the  normal  air-space.  It  is  not  diag- 
nostic. The  'physical  signs  of  pleural  effusion  have  been  frequently 
reiterated.  The  most  decisive  are  diminution  or  absence  of  movement, 
enlargement  of  the  affected  side,  absence  of  fremitus,  flatness  on  per- 
cussion, fulness  of  intercostal  spaces,  and  the  displacement  of  organs. 
The  latter  is  of  the  greatest  diagnostic  importance  in  the  distinction 
between  consolidation  and  effusions.  The  results  of  exploratory  punc- 
ture lead  to  decisive  conclusions  usually,  although  it  must  not  be  for- 
gotten that  effusions  may  be  loculated  and  therefore  missed  by  the 
aspirating-needle.  Or  the  enormously  thickened  pleura  may  intervene 
between  the  exudation  and  the  surface  of  the  chest,  and  prevent  with- 
drawal of  the  fluid.  Finally,  effusions  may  complicate  inflammatory 
processes,  as  pneumonia,  tuberculosis,  or  abscess  of  the  lung.  Secur- 
ing fluid  for  diagnosis  by  aspiration,  therefore,  does  not  necessarily 
exclude  these  conditions,  and  hence,  before  the  process  is  decided  to 
be  within  the  pleura  alone,  the  sputum  and  other  condition^  must  be 
taken  into  consideration. 

Differential  Diagnosis.  Acute  plastic  pleurisy  is  diagnosti- 
cated from  acute  pneumonia  by  the  friction-sound  and  the  maintenance 
of  the  clear  percussion-note  and  normal  respiratory  murmur,  with  unal- 
tered vocal  resonance  and  fremitus.  "When  effusion  takes  place  the 
chest  is  enlarged  and  immobile,  especially  on  the  affected  side;  the 
interspaces  are  filled  out  and  the  diaphragm  is  depressed  ;  these  changes 
do  not  occur  in  pneumonia.  Moreover,  the  percussion-note  in  pleural 
effusion  is  flat,  with. greatly  increased  resistance;  the  shape  of  the 
upper  line  of  dulness  is  diagnostic  ;  the  respiratory  murmur  is  feeble 
and  distant,  or  entirely  absent,  except  along  the  spine,  where  the  com- 
pressed lung  yields  bronchial  breathing,  and  also  above  the  line  of 
effu-ion,  where  the  lung  yields  exaggerated  breathing.  In  pneumonia, 
on  the  other  hand,  the  percus-ion-note  is  dull,  without  greatly  increased 
resistance,  and  the  breath-sounds  are  bronchial.  In  addition,  in 
pleurisy,  the  vocal  resonance  and  fremitus  are  usually  almost  if  not 
entirely  absent,  and  posteriorly  at  the  level  of  the  effusion  segophony 
may  be  detected.  In  pneumonia,  on  the  contrary,  vocal  resonance  and 
fremitus  are  increased  in  intensity.  In  pleurisy  with  effusion  the 
movable  organs  are  dislocated  and  Traube's  line  is  obliterated. 

Finally,  the  fever  of  pneumonia  is  much  higher  and  more  continuous 
than  that  of  pleurisy,  the  respirations  more  frequent,  the  cough  looser, 
and  in  typical  cases  followed  by  rusty  sputa.  (Compare  Fig.  GO  and 
Fig.  63.)  A  crucial  test  is  -  aspiration  with  a  hypodermic  needle  ; 
in  pleural  effusion,  serum  is  withdrawn;  in  pneumonia,  a  few  drops  of 
thick  blood. 

In  pleurodynia  there  is  also  severe  pain  in  one  side;  but  the  pain 
is  more  continuous  than  that  of  pleurisy,  and  consists  of  a  constant 
aching  or  a  burning  sensation.  It  is  made  worse  by  twisting  or  turn- 
ing, as  well  as  by  breathing.     The  side  is  also  tender  to  the  touch. 


348  SPECIAL  DIAGNOSIS. 

The  pain  is  not  so  sharply  localized  as  that  of  pleurisy,  and  may  leave 
one  side  and  affect  the  other.  It  is  unaccompanied  by  fever  or  friction- 
sound,  and  is  frequently  found  in  rheumatic  subjects. 

In  intercostal  neuralgia  there  is  the  same  absence  of  fever  and  fric- 
tion-souud.  The  pain,  however,  is  sharply  localized  as  in  pleurisy, 
but  is  of  the  darting  neuralgic  character,  and  is  associated  with  tender- 
ness at  the  points  of  exit  of  the  intercostal  nerves.  It  is  most  common 
in  women,  especially  if  they  have  uterine  disturbances.  It  is  more 
frequent  on  the  left  side,  and  just  beneath  the  mammary  gland. 

Chronic  Pleurisy. 

Chronic  dry,  or  plastic,  pleurisy  is  the  result  of  an  acute  attack,  or 
develops  insidiously  if  tuberculous.  It  causes  great  deformity  of  the 
chest  from  contraction,  and  compensatory  emphysema  of  the  healthy 
lung.  The  heart  is  dislocated  or  cannot  be  found  on  physical  examina- 
tion, because  it  is  overlapped  by  lung  or  is  drawn  behind  the  sternum. 
There  is  considerable  spinal  curvature,  dislocation  of  the  scapula, 
deformity  of  the  shoulder,  and  indrawing  and  overlapping  of  the  ribs 
at  the  base  of  the  chest. 

Chronic  pleurisy  with  effusion  results  from  an  acute  attack  of  pleu- 
risy, in  which  the  fluid  remains  unabsorbed,  or  from  subsequent  attacks. 
The  physical  signs  are  the  same  as  in  acute  effusion.  So  far  as  subjec- 
tive symptoms  go  it  may  remain  latent ;  patients  so  affected  not  infre- 
quently go  about  their  work  with  comparatively  little  dy.-pnoea.  There 
may  be  an  evening  rise  of  temperature  and  acceleration  of  the  pulse. 
Chronic  effusions  are  more  likely  to  be  purulent  in  children  than  in 
adult*.  When  empyema  results,  the  fever  becomes  hectic  ;  there  are 
chills  and  sweats,  pyeemia  develops,  and  death  is  likely  to  occur  from 
some  intercurrent  suppuration,  as  cerebral  abscess. 

After  chronic  effusion  the  chest  is  rarely  restored  to  its  original  shape, 
even  if  the  effusion  is  finally  absorbed.  The  affected  side  becomes 
motionless  and  retracted.  In  process  of  time  the  spine  may  be  bent. 
The  opposite  lung  becomes  hypertrophied.  The  patient  is  usually  in 
precarious  health,  liable  to  acute  attacks  of  pain  in  the  affected  side, 
and  liable  also  to  be  carried  off  by  phthisis  or  some  intercurrent  affec- 
tion. Rarely  the  patient  may  maintain  good  health  ;  complete  cure 
is  even  possible,  with  restoration  of  the  retracted  side  to,  or  almost  to, 
normal  dimensions,  especially  in  children. 

Pneumothorax. 

Pneumothorax  consist*  in  an  accumulation  of  air  in  the  pleural  cavity, 
accompanied  or  followed  by  an  outpouring  of  fluid,  which  may  be 
serous  or  purulent,  constituting  respectively  hydro-pneumothorax  and 
pyo- pneumothorax. 

Pneumothorax  may  originate  :  1.  In  causes  external  to  the  chest,  by 
perforation  of  the  chest-wall  and  pleura.  2.  In  perforation  of  the 
lungs,  bronchi,  or  oesophagus.  3.  It  may  be.  caused  by  gases  devel- 
oped from  an  existing  effusion. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  349 

The  most  frequent  cause  is  tubercular  disease  of  the  lung,  and  next 
an  empyema  ;  out  of  121  cases  collected  by  Saussier,  81  were  due  to 
phthisis  and  29  to  empyema.  It  may  occur  very  early  in  tubercle  of 
the  lung,  and  may  even  be  the  first  symptom  of  tubercular  disease  (see 
cases  referred  to  by  Fox  and  recorded  by  Louis  and  Chomel).  The 
left  side  is  affected  not  quite  twice  as  often  as  the  right ;  the  disease  is 
usually  unilateral.  The  onset  of  the  condition  is  usually  sudden. 
During  a  paroxysm  of  coughing  or  vomiting,  or  without  immediate 
cause,  there  is  an  escape  of  air  into  the  pleura,  and  in  the  majority  of 
cases  the  patient  at  once  complains  of  acute  pain  in  the  chest  and  ex- 
cessive dyspnoea  with  great  dread  of  impending  suffocation.  The 
patient  often  sinks  into  collapse  from  shock,  but  sudden  death  is  rare. 
If  the  escape  of  air  into  the  pleura  is  gradual,  there  will  be  less  pain 
and  dyspnoea.  The  chest  is  distended,  especially  on  the  affected  side ; 
the  percussion-note  is  a  bell-like  tympany  except  when  the  distention 
is  excessive  and  the  air  contained  is  under  great  tension,  when  the  note 
is  proportionately  duller  and  higher  in  pitch  ;  the  diaphragm  is  de- 
pressed and  the  heart  displaced,  unless  adhesions  prevent  it.  In  left 
pneumothorax  it  may  beat  on  the  right  side,  the  whole  mediastinum 
being  pushed  to  the  right  ;  in  right  pneumothorax  the  mediastinum 
may  be  pushed  to  the  left  nipple  ;  hence  there  is  resonance  over  the 
normal  cardiac  region.  The  pitch  of  the  percussion-note  may  be  raised 
when  the  mouth  is  closed,  and  lowered  when  it  is  open  (Wiutrich's 
change  of  note),  and  a  cracked-pot  sound  can  be  elicited  in  some  cases, 
but  this  occurs  only  when  the  communication  with  the  pleura  remains 
open. 

A  valuable  sign  of  pneumothorax  is  the  coin-test,  or,  as  Trousseau 
named  it,  the  Bruit  d'airain.  A  silver  coin  is  laid  upon  the  chest  and 
struck  with  another,  while  the  auscultator  applies  the  stethoscope  oppo- 
site to  the  point  struck,  or  over  any  part  of  the  side  distended  by  air. 
The  ringing  coin-sound  is  reproduced  with  great  intensity.  It  is 
pathognomonic,  and  the  outlines  of  the  cavity  can  be  traced  by  it. 

When  fluid  is  present,  as  it  usually  is,  there  will  be  the  ordinary 
signs  of  a  pleural  effusion,  which  have  been  sufficiently  dwelt  upon. 
The  fluid  is  more  mobile  in  pneumothorax,  however,  than  in  simple 
pleurisy,  so  that  its  level  changes  more  quickly  with  change  of  posture 
of  the  patient,  and  Hippocratie'  suecussion  is  readily  obtained.  This 
movable  dulness  is  a  very  valuable  sign — indeed,  almost  pathognomonic. 

As  the  lung  is  compressed  against  the  spine  by  the  air,  as  it  is  by 
the  fluid  in  pleurisy,  the  breath-sounds  are  feeble  or  absent,  except 
over  the  root  of  the  lung,  where  the  breathing  is  bronchial.  But  if 
the  lung  is  not  completely  collapsed,  amphoric  breathing  may  be  heart  1. 
the  air-chamber  of  the  pleura  acting  as  a  consonance-box  ;  it  may  be 
heard  with  both  inspiration  and  expiration,  or  only  with  expiration. 

Metallic  tinkling  is  a  sound  believed  to  be  due  to  the  vibration  of 
bubbling  bronchial  rales  re-echoed  through  the  air-chamber,  or  to  drops 
of  fluid  falling  from  above  upon  the  surface  of  the  effusion,  lb- 
echoing,  with  metallic  quality,  may  also  accompany  the  heart-sounds, 
and  in  cases  in  which  the  respiratory  murmur  is  amphoric  the  vocal 
resonance  is  of  the  same  character.    Vocal  fremitus  is  generally  absent. 


350  SPECIAL  DIAGNOSIS. 

Differential  Diagxosis.  Pneumothorax  is  most  likely  to  be  con- 
founded with  (1)  emphysema;  (2)  tuberculosis  of  the  lungs  with  large 
cavities;  (3)  cases  of  pleural  effusion  in  which  above  the  upper  level 
of  the  fluid  the  lung  is  markedly  hyper-resonant;  and  (4)  abscess 
below  the  diaphragm  containing  air  (pyo-pneumothorax  subphrenicus). 

1.  Emphysema  can  be  distinguished  by  its  slow  onset,  its  relatively 
slight  impairment  of  the  general  health,  by  the  fact  that  it  is  bilateral, 
whereas  pneumothorax  is  almost  always  unilateral,  and  by  the  existence 
of  feeble  breathing  with  greatly  prolonged  expiration.  Amphoric 
breathing  and  resonance,  metallic  tinkling,  and  signs  of  fluid  are  all 
absent  in  emphysema. 

2.  When  the  pneumothorax  is  circumscribed  the  physical  signs  resem- 
ble those  of  pulmonary  cavity.  But  over  a  large  cavity  the  chest  is  usu- 
ally flattened;  cracked-pot  sound  and  alteration  in  pitch  upon  opening 
and  closing  the  mouth  are  more  common  in  cavity  than  in  pneumo- 
thorax. Displacement  of  viscera  does  not  necessarily  occur  in  phthisical 
cavity,  the  coin-test  is  negative,  succussion  cannot  .be  produced.  Fremi- 
tus is  absent  in  pneumothorax  and  increased  over  a  cavity. 

3.  The  hyper-resonance  above  a  pleural  effusion  develops  with  a  very 
different  clinical  histoiy,  is  accompanied  by  increase  of  fremitus  with 
bronchial  or,  at  times,  amphoric  breathing,  and  changes  when  the 
patient's  mouth  is  open  or  closed.  The  percussion-note  usually  lacks 
the  metallic  quality  heard  in  pneumothorax,  metallic  tinkling  is  absent, 
the  coin-test  is  negative. 

4.  Pneumothorax  must  be  distinguished  from  abscess  below  the  dia- 
phragm containing  air  {pyo-pneumothorax  subphrenicus).  Often  the 
distinction  is  difficult.  The  constitutional  symptoms  of  suppuration 
are  present  Leyden  points  out  the  importance  of  remembering  the 
sequence  of  events  in  the  development  of  the  disease.  AVhen  the 
abscess  is  situated  below  the  diaphragm,  abdominal  symptoms  precede 
its  development,  and  early  in  the  course  of  the  disease  there  is  ab- 
sence of  respiratory  symptoms.  If  the  patient  has  had  gastric  ulcer, 
this  would  point  to  subphrenic  abscess,  as  most  of  the  cases  of  sub- 
phrenic abscess  are  secondary  to  gastric  ulcer.  Moreover,  in  subphrenic 
abscess  the  heart  is  not  displaced  nor  the  interspaces  bulging.  Indeed 
the  viscera  below  the  diaphragm  are  more  likely  to  be  displaced  than 
those  above  it.  In  pneumothorax,  according  to  Leyden,  the  respiration 
is  normal  under  the  clavicle,  and  the  transitions  from  the  normal  to 
the  metallic  and  amphoric  sounds  lower  down  are  abrupt.  In  pyo- 
pneumothorax on  the  left  side  the  semilunar  space  disappears.  In 
subphrenic  abscess  the  amphoric  sounds  laterally  or  posteriorly  may 
be  above  and  below  the  diaphragm,  or  they  may  be  loudest  at  the 
epigastrium.  In  addition,  in  pyo  pneumothorax  subphrenicus,  as 
Mason  points  out,  adhesions  of  the  lung  to  the  diaphragm  and  parietes 
can  be  made  out,  particularly  if  the  case  has  been  under  observation  in 
its  earlier  stages  and  dry  pleurisy  has  been  discovered.  Abscess  in 
this  location  and  slight  fluctuation  are  likely  to  develop  with  associated 
effusion.  The  limited  extent  of  the  effusion  is  of  diagnostic  import  in 
favor  of  sub-diaphragmatic  inflammation. 


CHAPTER  III. 

DISEASES   OF   THE   HEART,   THE   BLOODVESSELS,   AXD 
THE  MEDIASTINUM. 

The  Heart. 

Before  discussing  the  symptoms  and  physical  signs  of  heart  dis- 
ease, a  brief  review  of  some  essential  facts  in  the  anatomy  and  physi- 
ology of  the  heart  is  of  importance. 

Anatomy.  The  heart  is  a  hollow  muscle,  composed  of  four  cham- 
bers. The  muscle  is  made  up  of  striated  fibre,  but  it  is  involuntary. 
The  exterior  is  covered  with  a  serous  membrane — the  pericardium, 
which  is  reflected  upon  the  sac  in  which  the  heart  hangs.  The  interior 
is  lined  with  membrane  of  the  same  histological  character — the  endo- 
cardium. The  chambers  are  four  in  number,  two  auricles  and  two  ven- 
tricles. The  auricles  are  at  the  upper  portion  or  base  of  the  heart ; 
the  ventricles  at  the  apex.  The  heart  is  divided  into  two  sides,  the 
right  and  the  left.  The  auricle  and  ventricle  of  each  side  are  related 
physiologically.  The  right  heart  draws  blood  from  the  veins  and  sup- 
plies it  to  the  pulmonary  circulation.  The  left  heart  belongs  to  the 
aortic  side  of  the  body,  the  major  or  arterial  circulation,  to  Avhich  it 
sends  blood,  while  it  draws  blood  from  the  pulmonic  circulation. 
Valves.  The  auricles  are  separated  from  the  ventricles  by  valves 
named  from  their  respective  positions,  the  right  and  left  auriculo- 
ventricular,  or  from  their  form  the  tricuspid  and  mitral  valves  of  the 
right  and  left  sides  respectively.  The  valves  close  during  the  systole, 
producing  the  systolic  sound,  and  open  during  the  diastole.  The  aortic 
and  pulmonary  valves  are  situated  at  the  orifices  of  the  respective  ves- 
sels, and  close  with  the  beginning  of  the  diastole,  producing  the  dias- 
tolic sound. 

The  heart  receives  its  supply  of  blood  from  the  coronary  arteries 
and  its  innervation  from  nerve-centres  in  the  medulla,  and  from  the 
sympathetic  ganglia  in  the  heart-muscle. 

Topographical  Anatomy.  The  form  and  position  of  the  heart, 
its  relation,  and  the  relation  of  its  anatomical  elements,  to  the  surface 
of  the  chest,  must  be  well  known  to  localize  the  results  of  disease,  such 
as  the  various  forms  of  valvulitis,  and  to  recognize  any  physical  altera- 
tions. 

Outline  of  Heart  on  Chest-wall.1  To  have  a  general  idea 
of  the  torm  and  position  of  the  heart,  map  its  outline  on  the  wall  of 
the  chest  as  follows  : 

(«)  To  define  the  base — i.  e.,  the  part  to  which  its  great  vessels  are 

1  From  Uolden :  Landmarks,  Medical  and  Surgical. 


352  SPECIAL  DIAGNOSIS. 

attached — draw  a  transverse  line  across  the  sternum,  corresponding 
with  the  upper  borders  of  the  third  costal  cartilages ;  continue  the  line 
half  an  inch  to  the  right  of  the  sternum  and  one  inch  to  the  left. 

(6)  To  find  the  apex,  mark  a  point  about  two  inches  below  the  left 
nipple,  and  one  inch  to  its  sternal  side.  This  point  will  be  between 
the  fifth  and  sixth  ribs. 

(c)  To  find  the  lower  border  (which  lies  on  the  central  tendon  of  the 
diaphragm),  draw  a  line,  slightly  curved  downward,  from  the  apex 
across  the  bottom  of  the  sternum  (not  the  ensiform  cartilage)  as  far  as 
its  right  edge. 

(d)  To  define  the  right  border  (formed  by  the  right  auricle),  continue 
the  last  line  upward  with  an  outward  curve,  so  as  to  join  the  right 
end  of  the  base. 

(e)  To  define  the  left  border  (formed  by  the  left  ventricle),  draw  a  line 
curving  to  the  left,  but  not  including  the  nipple,  from  the  left  end  of 
the  base  to  the  apex. 

Such  an  outline  shows  that  the  apex  of  the  heart  points  downward 
and  toward  the  left,  the  base  a  little  upward  and  toward  the  right;  that 
the  greater  part  of  it  lies  in  the  left  half  of  the  chest,  and  that  the  only 
part  which  lies  to  the  right  of  the  sternum  is  the  right  auricle.  A 
needle  introduced  iu  the  third,  fourth,  or  fifth  right  intercostal  space 
close  to  the  sternum  would  penetrate  the  lung  and  the  right  auricle. 

A  needle  passed  through  the  second  intercostal  space  close  to  the 
right  side  of  the  sternum  would  after  passing  through  the  lung, 
enter  the  pericardium  and  the  most  prominent  part  of  the  bulge  of  the 
aorta. 

A  needle  passed  through  the  first  intercostal  space  close  to  the  right 
side  of  the  sternum  would  pass  through  the  lung  and  enter  the  supe- 
rior vena  cava  above  the  pericardium. 

The  best  definition  of  that  part  of  the  precordial  region  which  is 
less  resonant  on  percussion  was  given  by  Dr.  Latham  years  ago  in  his 
"  Clinical  Lectures."  "  Make  a  circle  of  two  inches  in  diameter  round 
a  point  midway  between  the  nipple  and  the  end  of  the  sternum.  This 
circle  will  define  sufficiently,  or  for  all  practical  purposes,  that  part  of 
the  heart  which  lies  immediately  behind  the  wall  of  the  chest  and  is 
not  covered  by  lung  or  pleura." 

Apex  of  the  Heart.  The  apex  of  the  heart  pulsates  between 
the  fifth  and  sixth  ribs,  two  inches  below  the  nipple,  and  one  inch  to 
its  sternal  side.  The  place  and  extent,  however,  of  the  heart's  impulse 
vary  a  little  with  the  position  of  the  body.  Of  this,  anyone  may 
convince  himself  by  leaning  forward,  backward,  on  this  side,  and  on 
that,  at  the  same  time  feeling  the  heart.  Inspiration  and  expiration 
also  alter  the  position  of  the  heart.  In  a  deep  inspiration  it  may 
descend  half  an  inch,  and  can  be  felt  beating  at  the  pit  of  the  stomach. 

Valves  op  the  Heart.  The  aortic  valve  lies  behind  the  third 
intercostal  space,  close  to  the  left  side  of  the  sternum. 

The  pulmonary  valve  lies  in  front  of  the  aortic  behind  the  junction 
of  the  third  costal  cartilage  with  the  sternum,  on  the  left  side. 

The  tricuspid  valve  lies  behind  the  middle  of  the  sternum,  about  the 
level  of  the  fourth  costal  cartilage. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     353 

The  mitral  valve  (the  deepest  of  all)  lies  behind  the  third  intercostal 
space,  about  one  inch  to  the  left  of  the  sternum. 

Thus  these  valves  are  so  situated  that  the  mouth  of  an  ordinary- 
sized  stethoscope  will  cover  a  portion  of  them  all,  if  placed  over  the 
sternal  end  of  the  third  intercostal  space,  on  the  left  side.  All  are 
covered  by  a  thin  layer  of  lung;  therefore  we  hear  their  action  better 
when  the  breathing  is  for  a  moment  suspended. 

Action  of  the  Heart.  The  heart  beats — that  is,  alternately  con- 
tracts and  dilates  or  relaxes — 65  to  85  times  per  minute  in  an  adult. 
In  females,  the  frequency  varies  from  75  to  85;  in  males  from  65  to 
75.  With  each  beat,  blood  is  propelled  throughout  the  vascular  chan- 
nels of  the  body,  and  drawn  from  them  to  the  heart- chamber  The 
first  effect  is  produced  by  the  contraction  of  the  heart,  or  the  systole  ; 
the  second  by  the  relaxation,  or  diastole.  Other  events,  as  the  act  of 
respiration,  contribute  to  the  completion  of  the  outflow  and  inflow  of 
blood,  particularly  to  the  latter. 

The  completion  of  the  act  of  contraction  and  the  act  of  dilatation 
make  up  one  revolution  of  cardiac  action,  or,  as  it  is  termed,  a  cycle. 

Events  of  the  Cardiac  Cycle.  The  following  events  make  up  the 
cardiac  cycle.  The  act  of  contraction  is  the  systolic  period  of  the 
cycle  ;  that  of  relaxation  is  the  diastolic  period.  During  the  systole 
(1)  the  ventricles  contract  ;  (2)  the  auriculo- ventricular  valves  close  ; 
(3)  the  blood  is  propelled  from  the  ventricles  into  the  vessels,  the  col- 
umns of  blood  in  the  aorta  and  pulmonary  artery  receive  a  shock  from 
the  impact  of  the  new  volume  of  blood,  and  their  bulk  increases.  The 
movement  of  the  blood-wave  from  this  cause  and  from  the  contraction 
of  the  large  vascular  trunks  produces  pulsation  of  the  peripheral  vessels, 
which  is  known  as  the  pulse.  The  contraction  is  immediately  followed 
by  relaxation — the  diastole.  (1)  The  blood-columns  in  the  aorta  and  in 
the  pulmonary  artery  fall  back  upon  the  valves  guarding  their  outlets, 
the  aortic  and  pulmonary  valves.  At  the  same  time  (2)  the  auricles  are 
filled  by  the  blood  pouring  in  from  the  veins.  (3)  The  auricular 
muscles  contract  upon  the  blood  in  the  chamber,  driving  it  into  the 
ventricles. 

The  systolic  and  the  diastolic  periods  of  a  cardiac  cycle  are  nearly 
equal  in  the  length  of  time  occupied  in  their  occurrence.  The  systolic 
period  occurs  at  the  same  time,  or  is  synchronous  with  the  apex-beat 
and  carotid  pulse,  and  precedes  by  a  fraction  of  a  second  the  radial 
pulse.  It  is  immediately  followed  by  the  diastolic  period,  which,  there- 
fore, follows  the  carotid  and  radial  pulse. 

Symptomatology.  The  symptoms  of  disease  of  the  heart  are  due 
to  the  anatomical  structure  of  the  organ,  to  its  physiological  offices, 
and  to  the  morbid  process.  The  heart  is  a  hollow  muscular  structure 
which  hangs  in  a  cavity  and  encloses  cavities  separated  by  valves. 
Both  sets  of  cavities  are  lined  by  serous  membrane.  The  serous  mem- 
branes are  subject  to  the  same  diseases,  which,  in  turn,  present  the 
same  symptoms  as  diseased  serous  membranes  elsewhere.  In  inflam- 
mation of  the  externa]  membrane  the  surfaces  rub  together  and  create 
a  sound  of  friction.  The  external  serous  cavity  may  also  become  filled 
with  the  products  of  exudation  or  transudation.      Physical  signs  are 

23 


354  SPECIAL  DIAGNOSIS. 

produced.  They  are  the  physical  signs  of  a  localized  increase  of  con- 
tents as  determined  by  inspection,  palpation,  and  percussion,  and 
of  physical  interference  with  the  heart's  action.  The  heart-muscle  is 
also  subject  to  the  same  morbid  processes  as  other  muscular  structures. 
They  are  hypertrophy  and  atrophy;  inflammation,  acute  and  chronic, 
with  overgrowth  of  connective  tissue;  and  degenerations.  The  symp- 
toms are  likewise  the  same.  Increase  or  diminution  in  the  power  of 
the  muscle  is  associated  with  corresponding  change  in  size,  which  is 
determined  by  physical  signs.  Above  all,  however,  such  change 
modifies  the  heart's  action  so  that  strength  or  weakness  of  the  niuscle 
shows  itself  in  excessive  or  deficient  vascular  pressure.  The  latter 
is  more  particularly  an  object  of  observation  because  of  the  conges- 
tions, dropsies,  and  cyanosis  that  ensue. 

The  heart  is  constantly  subjected  to  internal  pressure.  Dilatation  of 
the  cavities  or  a  portion  of  cavity  (aneurism)  follows  previous  disease 
of  the  muscle  or  increase  of  internal  pressure,  and  causes  physical 
signs  of  enlargement.  Degeneration  of  the  heart-muscle,  nearly  always 
secondary  to  deficiency  of  vascular  supply,  is  also  attended  by  symp- 
toms of  weakness  and  physical  signs  of  enlargement  (dilatation),  or  of 
diminution  in  size  (atrophy).  When  dilatation  occurs  the  orifices  of 
the  cavities  enlarge,  the  valves  cannot  close  them,  and  symptoms  of 
incompetency  and  of  blood-regurgitation  result. 

The  serous  membrane  that  lines  the  cavities  of  the  heart  and,  with 
the  subserous  tissues,  makes  up  the  structure  of  the  valves,  is  subject 
to  inflammations,  the  symptoms  of  which  are  common  to  all  serous 
inflammations.  The  swellings  and  outgrowths  that  attend  such  inflam- 
mation occlude  the  orifices  and  prevent  closing  of  the  valves.  A  phy- 
sical interference  with  the  heart's  function  is  produced,  recognized  by 
physical  signs.  The  successful  effort  of  the  heart-muscle  to  overcome 
such  obstruction  on  the  one  hand  (hypertrophy),  or  its  failure  on  the 
other  (dilatation),  again  leads  to  the  production  of  symptoms  and  signs. 
The  serous  membranes,  and  hence  the  valves,  are  exposed  to  causes 
which  excite  inflammation.  By  virtue  of  the  position  of  the  heart  at 
the  centre  of  the  circulation,  the  blood,  infectious  or  irritative,  as  in 
rheumatism  and  Bright' s  disease,  constantly  bathes  the  vulnerable 
structure.  For  the  same  anatomical  reason  positive  symptoms  arise, 
not  common  to  serous  membrane  inflammation — that  is,  embolic  phe- 
nomena (see  Symptoms  of  Morbid  Processes).  Hence,  the  physical 
signs  (objective  symptoms)  of  cardiac  disease  may  be  due  to  primary 
and  secondary  morbid  anatomical  changes.  They  may  be  due  (1)  to 
valvulitis  as  indicated  by  signs  of  (a)  obstruction  or  regurgitation  at  the 
valve-orifice,  or  (6)  of  embolic  phenomena;  (2)  to  secondary  changes 
in  the  heart-muscle  as  seen  in  (a)  change  in  the  size  and  strength  of 
the  organ,  and  (6)  secondarily  in  congestion,  oedema,  cyanosis,  etc. 

It  is  the  function  of  the  heart  to  propel  the  blood.  It  has  been 
shown  how  interference  with  the  action  of  the  muscle  and  with  the 
consequent  flow  of  blood  through  the  cavities  and  orifices  modifies  the 
function.  The  functional  power  is  increased  or  diminished  by  the 
physical  changes.  The  evidence  of  increased  power  is  increased  force 
of   the   heart-beat,    and   increased   pressure  in   the   arteries    (pulse). 


DISEASES  OF  HEART,  BL 0 OD  VESSELS,  AND  MEDIASTINUM.     355 

Diminished  power  shows  itself  in  symptoms  of  diminished  blood-sup- 
ply to  parts,  and  in  stagnation  of  the  blood  that  is  sent  to  the  periphery. 
The  former  is  more  pronounced  in  cerebral  anaemia,  and  physiological 
weakness  of  organs  or  the  organism  as  a  whole  ;  the  latter,  in  conges- 
tions and  dropsies. 

The  functional  activity  of  the  heart  is  controlled  by  a  nervous  mech- 
anism, any  alteration  of  Avhich  alters  cardiac  action  and  consequently 
produces  symptoms.  Just  as  with  the  larynx,  a  break  in  the  cardiac 
mechanism  may  be  in  the  centres  in  the  medulla,  the  centres  in  the 
muscle,  or  in  the  sympathetic  nerves  to  and  from  the  heart.  The  rich 
anastomosis  of  these  nerves  exposes  the  heart  to  disturbance  by  reflex 
influences.  We  should  suppose  such  extensive  innervation  would 
invite  frequent  cardiac  perturbation.  In  a  measure  it  does,  but,  for- 
tunately, so  perfect  is  this  mechanism  that  the  inhibitory  fibres  control 
such  perturbation  to  a  large  extent,  and  we  do  not  see  such  pronounced 
symptoms  as  occur  in  the  larynx.  The  symptoms  which  point  to  dis- 
turbance of  the  cardiac  mechanism  are  alterations  in  the  rhythm  of 
the  heart.  Its  action  may  on  this  account  be  increased  or  diminished 
in  frequency,  or  it  may  be  irregular  or  intermittent.  Such  alterations 
of  rhythm  may  be  due  to  organic  disease  of  the  centres,  notably  the 
pneumogastric  from  apoplexy,  softening,  or  tumor  in  the  medulla,  to 
stimulation  or  depression  of  the  centres  by  toxic  substances  in  the 
blood,  as  in  uraemia,  acetonsemia,  or  autogenetic  or  other  toxaemias,  or 
by  nicotine  or  other  extraneous  material.  The  altered  rhythm  may 
be,  and  most  frequently  is,  of  reflex  origin.  It  may  be  due  to  disease 
of  the  nerves,  as  the  pneumogastric  or  sympathetic,  from  pressure  upon 
the  nerve-trunk  by  tumor  or  inflammatory  growth.  The  most  pro- 
nounced symptom  of  altered  rhythm  of  which  the  patient  is  cognizant 
is  palpitation.  The  exciting  cause  of  this,  as  well  as  other  rhythmical 
changes,  must,  in  the  great  majority  of  cases,  be  sought  for  beyond 
the  domain  of  the  heart. 

While  the  symptoms  or  signs  of  cardiac  disease  are  often  due  to 
morbid  processes  in  the  organ  or  its  membrane,  it  must  be  remembered 
that  grave  and  persistent  subjective  and  objective  symptoms  may  be 
caused  by,  or  at  least  associated  with,  disease  of  contiguous  structures 
outside  of  the  pericardium.  The  symptoms  are  not  excited  through 
the  nervous  system,  but  are  produced  by  mechanical  encroachment 
upon  the  organ,  as  in  pleurisy  with  effuson,  mediastinal  disease  and 
disease  of  sub-diaphragmatic  viscera.  They  will  be  referred  to  in  the 
study  of  objective  symptoms.  Care  must  be  taken  never  to  overlook 
the  possibility  of  their  presence. 

In  the  study  of  the  symptomatology  of  cardiac  disease  the  student 
must  bear  in  mind  two  things  :  first,  that  the  cause  of  the  morbid  pro- 
cesses and  of  the  symptoms  (pain  and  palpitation)  may  be  elsewhere 
than  in  the  heart  ;  and,  second,  that  the  ultimate  object  of  the  exam- 
ination is  to  determine  the  muscular  power  of  the  heart.  He  will  soon 
learn  that  witli  that  power  intact  the  functions  can  be  performed,  not- 
withstanding the  presence  of  marked  physical  abnormalities. 

The  recognition  of  disease  of  the  heart  is  not  usually  attended  by 
much  difficulty,  except  in  some  special  lesions.      The  non-recognition 


356  SPECIAL  DIAGNOSIS. 

of  cardiac  disease  is  due  to  faults  in  the  examination.  The  physician 
is  too  often  satisfied  with  the  recognition  of  the  remote  process,  as  a 
congestion  or  functional  weakness  in  some  organ.  Safety  lies,  as  has 
often  been  said,  in  the  examination  of  all  the  organs  of  the  body. 
Often,  for  instance,  indigestion  from  gastric  catarrh  is  not  relieved  for 
the  cause,  mitral  regurgitation,  is  not  recognized. 


The  Data  Obtained  by  Observation. 

The  objective  signs  of  disease  of  the  heart  are  determined  by  the  same 
means  as  those  employed  in  the  detection  of  these  signs  elsewhere. 
In  order  to  ascertain  them  it  is  necessary  that  the  patient  should 
be  stripped,  and  a  good  light  should  fall  directly,  as  well  as  obliquely, 
on  the  surface.  The  patient  can  be  examined  in  any  position,  and 
indeed  for  accuracy  should  be  examined  in  the  upright  and  recumbent 
postures.  This  is  particularly  true  when  the  pulse-rate  is  taken  and 
when  auscultation  is  practised.  The  sounds  vary  frequently  in  different 
positions.  Some  diagnostic  significance  is  attached  to  these  variations. 
It  is  necessary  sometimes  to  have  the  patient  lean  forward,  to  bring  the 
heart  into  more  immediate  contact  with  the  chest- wall. 

Inspection.  Examination  with  the  eye  should  not  be  confined  to 
the  heart  alone.  The  reader  will  remember  that  in  the  description 
of  the  examination  of  the  exterior  and  of  local  areas,  it  Avas  pointed 
out  that  certain  abnormal  conditions  may  be  due  to  disease  of  the  heart. 
In  the  examination,  therefore,  of  a  case  of  suspected  heart  disease, 
observation  is  made  of  the  general  and  of  the  local  color,  as  of  the 
lips,  the  fingers,  and  the  conjunctivae,  to  determine  the  presence  of 
cyanosis,  pallor,  or  jaundice ;  of  the.  feet,  to  discover  dropsy  ;  the  face, 
to  note  the  appearance  of  the  countenance  ;  the  neck,  to  note  the  state 
of  the  vessels  ;  the  eyes,  to  note  their  prominence  ;  the  thorax,  to 
ascertain  the  presence  of  dyspnoea. 

The  Pr^cordia.  The  prsecordia  is  the  region  of  the  chest  which 
overlies  the  heart.  In  the  study  of  the  appearance  of  the  prsecordia 
we  observe  (1)  the  degree  of  prominence  or  bulging  of  the  chest 
in  that  region;  (2)  the  appearance  of  the  interspaces;  (3)  the  hue  of 
the  surface;  (4)  the  position  of  the  apex-beat;  (5)  the  extent  of  the 
impulse.  It  may  be  unduly  prominent  in  children  who  have  had 
rickets  and  possibly  some  cardiac  hypertrophy  in  childhood.  It 
persists  in  later  life.  The  bony  prsecordia  besides  the  soft  tissues  is 
prominent.  The  lower  end  of  the  sternum  may  project.  Bulging 
also  occurs  in  hypertrophy  or  dilated  hypertrophy  of  the  heart, 
and  in  pericardial  effusions,  and  localized  pleural  effusions,  and 
pointing  empyema,  and  aneurisms  in  the  region  of  the  heart.  In 
pericardial  effusion  ribs  and  interspaces  project.  The  latter  are  full 
or  bulging  even  with  the  surface.  The  prominence  of  cardiac  disease 
is  observed  between  the  third  and  seventh  ribs  on  the  left  side,  and 
extends  from  the  left  nipple  to  the  sternum,  and  even  as  far  as  the 
right  nipple.     The  distance  from  the  middle  of  the  sternum  to  the 


DISEASES  OF  HEAR  T,  BL  0  OD  VESSELS,  AND  MEDIASTIN UM.     357 

mid-axilla  is  greater  on  the  left  than  on  the  right  side.  Local  bulging 
may  be  seen  at  the  apex  in  cases  of  aneurism  of  the  heart. 

The  praecordia  may  be  sunken.  Old  pericarditis,  but  more  frequently 
old  empyema,  causes  sinking  in  of  the  region.  It  may  be  a  result 
of  rickets,  or  of  spinal  curvature. 

The  interspaces.  They  are  retracted  possibly  from  pericardial  adhe- 
sions; in  effusion  they  are  full  or  bulging.  Only  when  purulent  peri- 
cardial effusion  is  about  to  rupture,  or  an  empyema  to  discharge,  do 
we  note  redness  or  other  change  in  hue  of  the  surface  of  the  prsecordia, 
not  observed  over  the  remainder  of  the  thoracic  surface. 

The  Impulse.  The  impulse  is  observed  at  the  apex,  or  rather  that 
portion  of  the  heart  which  strikes  the  chest- wall,  and  is  known  as  the 
apex-beat.  It  is  evident  in  health  in  the  fifth  interspace  just  inside 
of  the  mid-clavicular  line.  It  can  readily  be  detected  by  inspection 
with  a  good  light,  in  patients  with  moderately  thick  chest-walls.  It 
is  due  to  the  impulse  of  the  right  ventricle,  three-fourths  of  an  inch 
above  the  apex,  against  the  chest- wall  when  the  heart  contracts,  and 
hence  it  is  systolic  in  time. 

Changes  of  position  in  health.  It  is  not  a  fixed  point  in  health.  It 
moves  with  the  movements  of  the  body,  and  hence,  when  the  trunk  is 
inclined  to  the  left,  the  impulse  falls  toward  the  left  axilla  as  far  out- 
ward as  the  mid-clavicular  line  or  even  beyond  that  point.  It  moves 
toward  the  right  and  downward  in  full  inspiration,  or  may  disappear 
entirely  toward  the  completion  of  that  act.  It  may  not  be  observed  if 
there  is  a  large  amount  of  subcutaneous  fat,  or  if  the  mammary  gland 
intervenes.  It  becomes  more  conspicuous  at  the  end  of  expiration  or 
when  the  body  is  inclined  forward.  In  children  it  is  higher  (fourth 
interspace)  and  more  to  the  left.  It  is  depressed  in  old  people.  It 
must  be  remembered  that  in  transposition  of  the  viscera  the  position  of 
the  impulse  is  changed. 

Change  of  position  of  impulse,  or  apex-beat,  in  disease.  The  apex- 
beat,  or  the  lowest  point  of  impulse,  may  be  displaced  or  may  be  absent 
entirely.  These  changes  are  due  either  to  (a)  disease  outside  of  the 
pericardium,  to  (6)  disease  within  the  pericardium,  or  to  (c)  disease  of 
the  heart  itself. 

Impulse  Displaced  to  the  Left.  This  occurs  from  (a)  Alterations  out- 
side  of  the  Pericardium.  When  the  right  lung  is  the  seat  of  extensive 
compensatory  emphysema,  or  the  right  pleura  filled  by  a  large  effusion, 
the  impulse  is  displaced  to  the  left.  On  the  other  hand,  fibroid  phthisis 
of  the  apex  of  the  left  lung,  or  pleural  adhesions  which  have  become 
attached  to  the  pericardial  sac,  with,  probably,  coincident  pericarditis, 
pull  the  heart  to  the  left,  thereby  changing  the  position  of  the  impulse. 
In  disease  of  the  mediastinum  the  heart  is  pushed  downward  and 
toward  the  left.  An  aneurism,  an  abscess,  or  enlarged  glands  in  this 
situation  may  invade  the  normal  cardiac  territory  and  cause  dislocation 
of  the  heart. 

In  disease  of  the  abdomen  the  impulse  is  displaced.  If  the  liver  and 
spleen  are  enlarged,  or  the  abdomen  distended  by  ascites,  the  diaphragm 
is  raised  and,  therefore,  also  the  heart.  '  The  impulse  is  then  seen  t<> 
the  left  of  the  normal  position,  and  may  be  one  or  two  interspaces 


358 


SPECIAL  DIAGXOSIS. 


higher  than  normal.  A  common  physical  change  in  the  stomach — 
dilatation — is  a  frequent  source  of  displacement  of  the  impulse.  The 
dilatation  may  be  temporary  from  flatulency  or  may  be  due  to  organic 
disease. 

(5)  Alterations  within  the  Pericardium.  In  cases  of  pericardial  effu- 
sion the  impulse  is  shifted  to  the  left  and  upward.  It  is  seen  in  the 
fourth  and  even  as  high  as  the  third  interspace,  and  sometimes  only  an 
impulse  is  noted  in  the  second  interspace.  This,  however,  is  not  the  true 
apex.  Instead  we  undoubtedly  see  in  pericardial  effusions  the  impulse 
of  the  right  auricle  and  the  conus  arteriosus  against  the  chest-wall. 

(c)  Diseases  of  the  Heart.  The  impulse  is  displaced  to  the  left  in 
dilatation  and  hypertrophy  of  the  heart.  In  the  latter  it  is  also  dis- 
placed downward.  It  may  be  as  low  as  the  sixth  or  seventh  inter- 
space and  extend  as  far  to  the  left  as  the  anterior  axillary  or  the  mid- 
axillarv  line. 


Fig.  65. 


Normal  and  abnormal  impulses. 
1.  Normal  position  of  impulse.    2.  Displacement  to  left  and  downward.    Z.  Displacement  to  left 
and  upward.     4.  Impulse  from  enlarged  right  ventricle.     5.  Displacement  to  right.    6.  Dilated 
right  auricle.    7.  Displacement  in  fibroid  phthisis.    8.  Impulse  of  conus  arteriosus.    9.  Fibroid 
phthisis,  right  lung. 

Impulse  Displaced  to  the  Right,  (a)  Alterations  outside  of  the  pericar- 
dium. The  heart  is  dislocated  to  the  right  in  left  pleural  effusion,  and 
in  emphysema  of  the  left  lung.  We  find,  moreover,  in  pleural  con- 
tractions and  in  fibroid  phthisis  of  the  right  lung,  the  heart  drawn  to 
that  side.  Under  these  circumstances  the  impulse  is  noted  either  in 
the  epigastric  region,  along  the  margin  of  the  ribs,  or  even  to  the  right 
nipple-line,  in  any  interspace  from  the  third  to  the  sixth,  along  the 
right  edge  of  the  sternum.  The  impulse  in  the  epigastric  region  usu- 
ally represents  the  hypertrophied  right  ventricle,  which  usually  attends 
the  lung-changes  that  cause  displacementof  the  apex-beat.  The  impulse 
along  the  right  edge  of  the  sternum  may  be  the  apex-beat,  or  the  right 
auricle  and  the  right  ventricle  brought  in  apposition  to  the  chest-wall 
by  the  cardiac  dislocation.  The  apex  or  the  tip  of  the  heart  is,  in  all 
probability,  displaced  but  little  beyond  the  mid-sternal  line.  (6)  The 
impulse  is  not  displaced  to  the  right  in  alterations  within  the  pericar- 
dium, or  (c)  in  disease  of  the  heart. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     359 

Impulse  Absent.  Following  the  same  order,  we  find  that  the  impulse 
may  be  absent  entirely  in  (a)  disease  outside  of  the  'pericardium  on  ac- 
count of  which  something  intervenes  between  the  heart  and  the  chest- 
wall.  Heuce,  in  emphysema  of  the  lungs  and  in  compensatory 
emphysema  of  the  left  lung,  the  impulse  is  entirely  effaced;  in  (6) 
disease  of  the  pericardium  the  impulse  is  absent  when  there  is  large 
effusion.  The  absence  here  succeeds  the  dislocation  to  the  left,  and 
with  its  effacement  the  impulse  in  the  second  and  third  interspaces 
disappears.  In  (c)  disease  of  the  heart  the  impulse  is  absent  when  the 
heart  is  diminished  in  size,  as  in  atrophy,  or  in  myocarditis,  or  when 
weakened  by  fatty  degeneration  or  dilatation. 

The  Extent  of  tete  Impulse.  In  health  the  impulse  is  limited 
in  extent  to  about  one  square  inch.  The  area  of  impulse  may  be 
increased  when  the  individual  leans  forward,  and  at  the  end  of  expi- 
ration. It  is  more  evident  when  the  chest-walls  are  thin,  and  less 
when  they  are  thick. 

Extent  in  Disease.  The  area  of  impulse  may  be  increased.  The 
causes  are :  (a)  diseases  outside  of  the  pericardium.  The  area  is  in- 
creased in  chronic  phthisis  with  fibrous  adhesions,  and  in  pleural  adhe- 
sions when  the  lung  is  drawn  away  from  the  surface  of  the  heart.  It 
is  increased  when  the  heart  is  pushed  against  the  chest-wall,  as  in 
aneurism  or  in  diseases  of  the  mediastinum,  from  inflammation  or  can- 
cer, or  other  mediastinal  growth.  The  impulse  is  seen  not  only  in  the 
third  and  fourth  interspaces,  but  also  as  high  as  the  second,  and  is  not 
limited  to  the  spaces  between  the  sternum  and  parasternal  lines,  but 
may  extend  beyond  the  mid- clavicular  line.  It  may  not  be  systolic  in 
time  only,  but  diastolic,  presystolic,  and  systolic,  and  have  the  appear- 
ance of  a  peristaltic  wave  from  base  to  apex.  The  time  coincides  not 
only  with  contraction  of  the  ventricles,  but  also  of  the  auricles,  and 
of  the  closure  of  the  semilunar  valves.  (6)  Disease  of  the  pericar- 
dium tends  to  increase  the  area  of  impulse  if  moderate  effusion  is 
present.  It  will  be  seen  as  a  diffuse  wave  occupying  the  second,  third, 
and  fourth  interspaces.  It  is  also  increased  in  pericardial  adhesions, 
without  increase  in  strength.  (c)  Disease  of  the  heart.  The  heart 
must  be  enlarged,  and  hence  must  be  either  hypertrophied  or  dilated. 
The  extent  of  impulse  varies.  In  hypertrophy  the  impulse  may  be 
communicated  to  the  sternum,  so  that  the  lower  part  heaves  with  each 
contraction.  It  falls  below  the  fifth  interspace  and  toward  the  left, 
particularly  if  the  left  ventricle  is  the  seat  of  the  enlargement.  If 
the  right  ventricle  is  hypertrophied,  the  impulse  is  very  marked  in 
the  third,  fourth,  fifth,  sixth,  and  even  the  seventh  interspaces  near 
the  termination  of  the  cartilages,  or  in  the  epigastrium  along  the  border 
of  the  ribs  of  the  left  side.  It  may  be  seen  in  anaemia  in  this  situa- 
tion, particularly  in  persons  whose  respirations  are  habitually  shallow. 
Sometimes,  when  associated  with  and  displaced  by  lung  disease,  it  is 
seen  to  the  right  of  the  xiphoid  cartilage. 

New  Inijiuls, .  New  areas  of  impulse,  the  heart  not  dislocated,  arise 
from  enlargement  of  one  of  the  cardiac  chambers  or  from  disease  of 
the  bloodvessels.  A  new  area  of  impulse  in  the  second  or  third  inter- 
space on  the  left  is  from  the  conns  arteriosus,  or  is  due  to  hypertrophy 


360  SPECIAL  DIA  GNOSIS. 

and  dilatation  of  the  right  ventricle  ;  or  it  may  be  due  to  retraction  of 
the  lung  in  that  region.  It  may  be  due  to  a  dilated  right  auricle, 
and  is  then  seen  in  the  fifth  right  interspace  along  the  sternum.  If 
the  impulse  is  noted  in  the  course  of  or  adjacent  to  the  aorta,  it  is 
indicative  of  aneurism. 

Retraction  of  Interspaces.  In  place  of  swelling  or  projection  of  the 
interspace  or  interspaces,  rhythmical  retraction  sometimes  takes  place. 
This  retraction  may  be  limited  to  the  apex  or  may  occur  in  each  inter- 
space over  the  precordial  region.  It  may  "occur  with  the  systole  or 
with  the  diastole.  It  may  occur  in  hypertrophy  of  the  heart  and  is 
then  systolic  in  time.  It  is  of  some,  although  doubtful,  diagnostic 
significance  when  it  is  systolic  in  time,  and  is  said  to  indicate  adhesions 
of  the  pericardium,  traction  upon  which  by  the  systole  of  the  heart 
causes  the  interspaces  to  be  drawn  in.  The  adhesions  may  prevent  the 
lungs  overlapping  the  heart,  so  that  the  area  of  impulse  and  position 
of  the  apex  are  not  changed  by  full  inspiration.     (See  Pericarditis.) 

Palpation.  Palpation  confirms  inspection  as  to  the  shape  of  the 
prsecorclia,  the  condition  of  the  intercostal  spaces,  the  position  and 
the  extent  of  the  impulse.  In  addition  we  determine  by  palpation 
the  character  and  strength  of  the  impulse,  and  the  presence  or  absence 
of  valve-shock  and  of  thrills.  Palpation  also  reveals  oedema  of  the 
surface  and  fluctuation. 

The  Impulse.  In  a  normal  chest  with  moderate  walls  a  slightly 
prolonged,  moderately  strong  shock  is  transmitted  to  the  hand  when 
placed  over  the  prsecordia.  It  is  synchronous  with  the  cardiac  and 
precedes  the  radial  pulse.  It  is  therefore  systolic  in  time.  It  is 
stronger  when  the  patient  leans  forward,  exhales  freely,  removing  the 
lung  from  the  surface,  and  when  the  chest-walls  are  thin;  it  is  weaker 
in  opposite  conditions. 

Character  and  Strength  of  Impulse.  A.  Strength  increased.  1. 
Overaction.  In  the  violent  action  of  the  heart  that  attends  palpita- 
tion, and  in  the  increased  action  in  the  early  stages  of  fevers  or  of 
inflammation,  the  force  of  the  cardiac  impulse  is  much  increased. 
2.  Disease,  (a)  Alterations  outside  of  the  pericardium.  Increase  in 
the  extent  of  the  impulse  is  attended  by  increased  strength  when 
the  heart  is  hypertrophied  or  the  lung  retracted.  (b)  Alterations 
within  the  pericardium.  In  pericardial  adhesions  the  heart  is  held 
more  firmly  against  the  wall  and  may  give  the  appearance  of  strength 
to  the  impulse,  (c)  Disease  of  the  heart.  True  increase  in  force  of 
the  impulse  is  seen  in  disease  of  the  heart.  When  the  organ  is 
hypertrophied  or  the  seat  of  dilated  hypertrophy  the  force  _of  the 
impulse  is  increased,  sometimes  to  an  almost  unbearable  degree.  Up- 
lifting of  the  precordial  area  or  even  of  the  lower  half  of  the  aute- 
rior  part  of  the  chest  is  seen.  The  hand  or  the  head  laid  over  the 
heart  is  forcibly  lifted  with  each  systolic  contraction.  This  great 
force  is  most  pronounced  in  the  enormous  hypertrophy  that  occurs  in 
cases  of  aortic  obstruction.  It  is  the  impulse  and  force  of  the  so-called 
cor  bovinum.      In  dilatation  the  impulse  is  diffused  and  wavy. 

B.  Strength  lessened.      This  occurs  from  causes  which  diminish  the 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     361 

extent  of  the  impulse  or  cause  it  to  be  absent  entirely,  as  when  mate- 
rial intervenes  between  the  heart  and  the  chest-wall,  or  the  heart  is 
weakened  by  disease.  Hence  (following  the  classification  above)  (a) 
in  emphysema  of  the  lung  ;  (6)  in  pericardial  effusions  ;  (c)  in  fatty 
heart,  or  myocarditis,  in  dilatation,  and  simple  weakness  of  the  heart, 
the  strength  of  impulse  is  lessened. 

Valve-shock.  The  shock  of  the  closure  of  the  valves  can  be  felt 
by  the  hand  when  placed  evenly  over  the  praecordia.  The  shock  from 
the  pulmonary  and  aortic  valves  is  best  transmitted.  It  is  felt  most 
distinctly  in  persons  with  thin  chest- walls,  and  when  there  is  heightened 
tension  either  in  the  aorta  or  pulmonary  artery.  The  shock  follows 
the  impulse.  It  may  be  localized  more  accurately  with  the  finger-tips 
in  the  third  or  fourth  interspace  along  the  left  edge  of  the  sternum. 
The  shock  of  the  auriculo-ventricular  flaps  is  also  transmitted.  The 
shock  is  synchronous  with  the  first  sound.  It  is  felt  in  the  left  fourth 
interspace  near  the  sternum,  sometimes  over  it.  It  is  due  to  dilatation 
of  the  heart,  and  is  more  readily  felt  in  thin-chested  persons. 

Fig.  66. 


Abnormal  palpable  impulse  and  thrills. 
1.  Diastolic  impulse  palpable  from  closure  of  pulmonic  valve.    2.  Presystolic  impulse  in  mitral 
obstruction.    3.  Thrill  at  aortic  orifice  ;  systolic  obstruction  ;  diastolic  regurgitation.   4.  Thrill  at 
pulmonary  orifice ;  systolic  obstruction ;  diastolic  regurgitation.    5.  Thrill  at  mitral  orifice  ;  sys- 
tolic regurgitation  ;  diastolic  obstruction  ;  presystolic  obstruction.    6.  Thrill  at  tricuspid  orifice. 

Thrills.  A  thrill  is  produced  when  the  blood  is  thrown  into  vibra- 
tion by  passing  over  a  rough  surface.  It  may  be  created  with  the 
systole  or  during  the  diastole.  It  can  only  be  created  at  the  time 
blood  is  passing  through  the  orifices.  1.  The  most  common  scat  of 
the  thrill  is  the  apex.  If  the  hand  is  placed  in  close  proximity  to  the 
surface  of  the  chest  at  this  point,  a  vibration  or  tremor  is  transmitted 
to  it  in  most  cases  of  mitral  obstruction.  The  blood  is  passing  from 
the  auricle  to  the  ventricle  ;  as  this  takes  place  before  the  systole,  the 
thrill  is  felt  before  the  impulse  or  carotid  pulse.  It  is  presystolic  in 
time.  It  is  sometimes  difficult,  however,  to  distinguish  it  from  the 
impulse.  Its  character  cannot  well  be.  described.  The  hesitatiug, 
jogging  mauner  of  the  vibrations  or  the  thrill  is  clearly  transmitted  to 


362  SPECIAL  DIAGNOSIS. 

the  hand.  2.  The  next  most  frequent  seat  of  thrill  is  the  second 
costal  cartilage  on  the  right.  Here  the  thrill  or  vibration  is  systolic  in 
time  and  is  caused  by  obstruction  at  the  aortic  orifice.  It  may  be  felt 
away  from  the  heart,  in  the  aorta,  or  in  the  carotids.  The  aortic 
cusps  are  thickened,  contracted,  and  stiffened  by  a  sclerotic  endocar- 
ditis, or  the  orifice  is  occluded  by  valvulitis.  3.  Sometimes  a  thrill 
is  felt  at  the  apex  with  the  systole — first  sound.  This  occurs  rarely, 
but  must  not  be  confounded  with  the  before-first-sound  thrill.  It  is 
never  so  distinct,  and  is  not  made  up  of  a  series  of  vibrations.  It  is  due 
to  regurgitation  at  the  mitral  orifice.  4.  Rarely  a  thrill  is  felt  at  the 
second  costal  cartilage  on  the  right,  with  the  second  sound.  It  may  be 
felt  along  the  course  of  the  sternum  also,  and  is  due  to  regurgitation 
through  the  aortic  orifice.  The  systolic  thrill  must  not  be  confounded 
with  the  thrill  elicited  over  the  aorta  or  at  the  aortic  cartilage,  which 
is  due  to  aneurism.  5.  At  the  second  costal  cartilage  on  the  left  a 
thrill  is  sometimes  felt.  It  is  systolic  in  time  and  is  not  transmitted. 
It  is  due  to  obstruction  at  the  pulmonary  orifice.  6.  At  the  lower  por- 
tion of  the  sternum  a  thrill  systolic  in  time  is  also  felt,  due  to  tricuspid 
regurgitation.  Care  must  be  taken  not  to  confound  the  above-men- 
tioned thrills  with  those  due  to  aneurism  (see  Aneurism). 

Pericardial  Friction.  In  addition  to  the  thrills,  a  friction  or 
to-and-fro  rubbing  is  transmitted  to  the  hand  in  cases  of  pericarditis, 
in  the  first  stage.  The  friction  may  be  felt  all  over  the  heart  region, 
but  is  pronounced  in  the  third  or  fourth  interspace.  It  may  be  de- 
tected on  slight  pressure  or  only  when  the  tips  of  the  fingers  are  pressed 
firmly  against  the  interspaces. 

It  is  important  to  remember  that  the  ]iosition  of  the  patient  weakens 
or  modifies  the  thrill  or  friction.  When  the  patient  is  lying  down  it 
may  not  be  felt.  The  upright  posture  or  leaning  forward  makes  it 
evident,  and  hence  the  patient  should  be  instructed,  if  possible,  to 
assume  this  position  in  the  examination. 

Percussion.  By  means  of  percussion  the  shape  and  size  of  the 
heart  and  the  area  of  cardiac  dulness  are  determined.  The  lungs 
overlap  the  heart  and,  in  inspiration,  allow  a  small  area  to  be  in  con- 
tact with  the  chest-wall.  To  determine  the  size  of  the  heart,  both 
superficial,  or  light,  and  deep,  or  strong,  percussion  must  be  employed. 
By  the  former  we  determine  the  area  of  superficial  or  absolute  cardiac 
dulness  ;  by  the  latter,  the  area  of  deep  cardiac  dulness. 

1.  The  Area  of  Superficial  or  Absolute  Cardiac  Dul- 
ness. It  is  the  area  not  covered  by  the  lung  at  the  time  of  inspira- 
tion. The  percussion-force  employed  must  be  light,  so  as  to  elicit  the 
resonance  of  the  extreme  thin  edge  of  the  lung.  The  area  extends 
from  the  fourth  to  the  sixth  costal  cartilages.  The  right  border  may 
be  defined  by  a  line  drawn  between  two  points  fixed  on  the  median 
line  of  the  sternum  opposite  the  cartilages  above  indicated.  Join  the 
upper  point  witli  the  position  occupied  by  the  apex-beat. 

This  line  marks  the  upper  and  left  border.  A  line  joining  the  apex 
and  the  point  on  the  median  line  of  the  sternum  opposite  the  sixth  costal 
cartilage,  and  above  the  ensiform  cartilage,  marks  the  lower  border. 

31elhod.     The  right  border  is  determined  by  percussing  from  without 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     363 

inward  to  the  median  line.  Always  begin  to  percuss  far  enough  from 
the  sternal  edge  to  get  the  clear  pulmonary  note.  To  insure  uniform- 
ity, select  a  definite  area  from  which  to  start  in  all  cases.  Apply  the 
finger  vertically  at  first.  The  right  border  may  correspond  with  a  line 
outside  of  or  along  the  right  edge  of  the  sternum,  with  the  median  line 
or  the  left  edge  of  the  sternum,  or  even  beyond  the  latter.  After  the 
edge  of  modified  resonance  is  reached,  percuss  with  the  finger  parallel 
to  the  ribs,  to  control  the  result  previously  secured,  and  as  each  inter- 
space is  percussed  the  upper  limit  of  liver-dulness  and  the  triangle 
between  the  liver  and  heart  may  be  determined. 


Fig.  67. 


Showing  percussion  of  the  heart  and  liver,  the  degree  of  shading  indicating  the  degree  of  dul- 
ness.  The  margin  of  the  lung  is  indicated  by  the  dotted  lines.  The  liver  is  enlarged.  (Gibson 
and  Russell.) 

The  left  edge  is  determined  by  percussing  in  vertical  lines  from  a 
point  near  the  axilla  toward  the  heart.  Opposite  the  second  and  third 
interspaces  on  the  right  side,  the  aorta,  and  on  the  left,  the  pulmonary 
artery  can  be  defined.  The  student  should  acquire  the  habit  of  pro- 
ceeding from  definite  fixed  positions  toward  the  heart,  and  to  observe 
the  changes  during  inspiration  and  expiration.  The  lower  border 
and  rounded  apex  cannot  be  defined  if  the  stomach  contains  food  or 
fluid.      It  is  triangular  in  shape,  with  the  apex  pointing  downward. 

Changes  in  Size.  The  superficial  area  of  dulness  or  absolute  dulness 
is  increased  in  pericardial  effusion  and  in  enlargement  of  the  heart. 
It  is  replaced  by  resonance  in  emphysema,  and  hence  absent  entirely, 
as  the  lung  overlaps  or  completely  covers  the  heart.  It  is  absent  when 
the  heart  is  drawn  under  the  lungs  by  adhesions,  and  when  there  is  air 
in  the  pleural  or  pericardial  sac. 


364  SPECIAL  DIAGNOSIS. 

Deep  Cardiac  Dulness.  It  is  of  the  greatest  importance  to 
ascertain  the  deep  or  relative  area  of  cardiac  dulness.  The  percussion 
must  be  strong.  The  best  method  is  that  advised  by  Gibson  and 
Russell.  Their  directions  are  as  follows  :  ' '  Begin  in  the  upper  left 
interspaces  sufficiently  far  out  from  the  sternum  to  secure  pulmonary 
resonance.  For  instance,  in  the  second  interspace  begin  in  the  mid- 
clavicular line  and  percuss  strongly.  As  soon  as  a  slight  alteration  in 
that  sound  is  noted,  the  point  is  indicated  by  a  mark.  The  second  or 
third  and  succeeding  interspaces  are  percussed  in  like  manner,  bearing 
in  mind  that  the  percussion  must  begin  further  out  in  each  interspace 
in  order  to  get  pure  resonance.  As  dulness  is  secured  in  each  space 
a  mark  is  made.  This  is  continued  to  the  apex  if  that  is  visible,  or  to 
the  base  of  the  chest.  By  joining  the  marks  in  each  interspace  with 
the  line  at  the  base  of  the  heart,  the  left  border  of  the  cardiac  dulness 
can  be  fixed/'  The  authors  correctly  point  out  that  in  this  way  the 
true  apex  of  the  heart  is  found,  enabling  auscultation  to  be  conducted 
more  accurately.  The  right  edge  of  the  vessels  and  of  the  heart  is 
defined  in  the  same  way.  The  difference  in  the  sound,  in  passing  from 
the  lung  to  the  heart,  is  not  so  distinct  along  the  right  border  as  along 
the  left.  The  authors  include  the  dulness  which  is  due  to  the  vessels 
at  the  base  of  the  heart,  and  hence  begin  percussion  in  the  higher  inter- 
spaces. This  is  proper,  because  it  is  impossible  to  delimit  the  two. 
The  dulness  of  the  vessels  is  not  so  marked,  however,  and  may  be 
indicated  by  simple  change  in  pitch  in  the  percussion-note.  The  lower 
border  of  cardiac  dulness  is  ascertained  with  difficulty,  because  of  its 
close  apposition  with  the  liver.  At  times  there  is  a  difference  in  the 
character  of  the  dulness  between  the  two  organs.  It  can  be  well  made 
out  by  stethoscopic  percussion.  This  may  not  be  so  pronounced  as  we 
pass  from  the  heart  to  the  liver  in  the  median  and  parasternal  lines. 
Toward  the  apex  the  difference  is  more  apparent.  The  cardio-hepatic 
triangle  is  the  more  or  less  resonant  area  in  the  right  fifth  interspace 
which  separates  the  right  heart  and  the  liver.  The  apex  of  the 
triangle  points  to  the  sternal  edge,  the  base  to  the  axilla.  The  up- 
per arm  corresponds  to  the  right  border  of  the  heart  ;  the  lower  is  the 
upper  limit  of  the  liver.  The  writer  has  been  teaching  and  practis- 
ing this  method  of  percussion  ever  since  it  was  proposed  by  the 
authors,  and  can  testify  to  its  accuracy  in  clinical  studies  and  the  ease 
with  which  students  are  able  to  practise  it. 

Deep  Dulness  Increased.  The  increase  in  the  area  of  relative  dul- 
ness in  all  directions  occurs  in  hypertrophy  of  the  heart  and  in  pericar- 
dial effusions.  The  increase  in  width  above  the  base  of  the  heart 
occurs  in  dilatation  and  aneurism  of  the  aorta.  Change  in  the-  position 
of  the  heart,  a  general  idea  of  which  is  obtained  by  inspection  and 
palpation,  always  changes  the  shape  and  extent  of  the  dulness.  The 
heart  should  be  accurately  delimited  when  displacements  have  taken 
place. 

Increase  or  Extension  of  Deep  Dulness  Upward  or  to  the  Right  or 
Left.  In  addition  to  general  increase  in  cardiac  dulness,  one  of  the 
boundaries  or  a  portion  of  the  boundary  may  be  increased  or  extended 
beyond  the  normal  line.      1.   Thus  the  area  of  dulness  may  extend 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     365 

upward.  It  may  be  followed  by  extension  of  the  right  and  left  boun- 
daries. The  relative  area  of  dulness  is  abolished.  The  change  from 
pulmonary  resonance  to  dulness  is  abrupt  and  decided.  The  area  of  dul- 
ness becomes  pyramidal  or  pyriform  in  shape.  It  is  due  to  effusion  in 
the  pericardium.  2.  Increase  in  dulness  to  the  left  occurs  in  enlargement 
of  the  heart  from  hypertrophy  or  dilatation.  If  the  dulness  extends  out- 
ward to  the  left  and  retains  the  triangular  shape,  with  the  apex  pointed, 
it  is  due  to  hypertrophy  of  the  left  ventricle.  If,  on  the  other  hand, 
it  becomes  quadrilateral  in  shape,  with  the  apex  rounded,  it  is  due  to 
dilatation  of  the  left  ventricle.  The  results  of  palpation  and  inspection 
aid  in  detecting  the  presence  of  one  or  the  other  of  the  two  conditions. 
3.  The  area  of  dulness  extends  to  the  right.  It  is  due  to  hypertrophy 
and  dilatation  of  the  right  auricle  and  ventricle.  If  the  auricle  is 
dilated,  the  right  edge  is  extended  beyond  the  normal  in  the  third  and 
fourth,  or  as  high  as  the  second  interspace.  With  this  increase  in 
dulness  there  are  also  seen  an  epigastric  impulse,  venous  turgescence, 
and  pulsation  of  the  veins  of  the  neck  or  of  the  liver.  4.  Increase  in 
the  area  of  dulness  over  the  bloodvessels  is  usually  due  to  aneurism.  It 
may  be  general,  as  in  dilatation  of  the  aorta,  or  local,  as  in  aneurism. 
Extension  of  the  dulness  outward  or  upward  from  the  normal  line  may 
be  found  at  the  right  of  the  sternum  (aneurism  of  the  ascending  aorta), 
or  over  the  first  bone  of  the  sternum  (aneurism,  of  the  transverse  aorta), 
or  to  the  left  just  above  the  cardiac  area,  In  the  last  case,  the  dul- 
ness is  an  extension  upward  of  the  normal  area  of  cardiac  dulness  with 
rounding  of  the  area  affected  ;  the  aneurism  is  situated  at  the  begin- 
ning of  the  aorta. 

Pleximetric,  Percussion.  For  more  accurate  cardiac  percussion,  San- 
som  recommends  the  use  of  a  pleximeter  designed  by  himself,  by  which 
delicate  shades  in  dulness  can  be  readily  heard.  The  pleximeter  is  a 
thin,  flat,  oblong  plate  one  inch  by  half  an  inch,  which  has  on  its 
upper  surface  a  column  rising  from  the  middle,  one  and  a  half  inches 
in  height,  which  is  surmounted  by  a  second  plate  three-eighths  to  three- 
fourths  of  an  inch,  set  parallel  with  the  lower  plate.  The  instrument  is 
held  between  the  fore-  and  middle-finger  of  the  left  hand,  the  sensitive 
tips  of  the  fingers  resting  on  the  upper  surface  of  the  larger  horizontal 
plate.  The  lower  surface  of  this  latter  is  held  close  to  the  wall  of  the 
chest,  and  percussion  with  one  or  two  fingers  of  the  right  hand  with 
an  even  and  not  too  forcible  stroke  from  the  wrist  is  made  upon  the 
upper  plate.  The  resulting  vibrations  are  transmitted  to  the  ear  and 
are  also  appreciated  by  the  digital  sense  of  touch,  so  that  both  senses 
aid  in  the  determination  of  the  nature  of  the  sound  produced. 

Method.  The  pleximeter  is  placed  with  its  long  diameter  parallel 
with  the  sternum,  about  midway  between  the  axilla  and  the  right  ster- 
nal border.  Percussion  is  made  upon  the  summit  of  the  column  by 
one  or  two  fingers,  and  the  pleximeter  is  moved,  always  in  parallel 
lines,  nearer  and  nearer  to  the  sternum.  A  line  is  reached  Avhere  the 
vibrations  are  modified.  Incline  the  pleximeter  so  that  the  vibrations 
come  from  its  left  edge.  This  edge,  or  line,  is  practically  the  line  of 
demarcation  of  the  dulness  and  should  be  indicated  with  an  aniline 
pencil.      It  corresponds  to  the  outline  of  the  right  border  of  the  heart 


366  SPECIAL  DIAGNOSIS. 

(see  Fig.  67).  The  process  must  be  repeated  at  higher  and  lower 
levels  until  the  entire  right  area  of  cardiac  or  aortic  dulness  is  ascer- 
tained. In  passing,  it  may  be  stated  that  percussing  from  above  down- 
ward with  the  long  diameter  of  the  pleximeter  horizontal  instead  of 
vertical  leads  to  the  upper  limit  of  the  liver  as  indicated  by  modified 
vibrations.  At  about  the  fifth  right  intercostal  space  a  short  curved 
line  is  thus  made  out  along  the  right  edge  of  the  sternum,  which  indi- 
cates the  outline  of  the  right  auricle  at  the  point  where  it  joins  the  liver- 
dulness.  Above  this,  as  far  as  the  second  rib,  the  line  indicates  the 
outline  of  the  right  border  of  the  auricle  and  the  aorta.  The  out- 
line of  the  auricle  may  be  in  the  mid  sternum;  of  the  aorta,  at  the  right 
edge.  In  percussing  the  left  side  of  the  chest  the  same  method  is 
adopted.  Begin  at  the  level  of  the  second  rib,  two  or  three  inches 
beyond  the  left  edge  of  the  sternum,  and  move  to  the  right.  Join 
the  lines  of  modified  vibrations,  and  in  this  manner  the  left  border  of 
cardiac  and  aortic  dulness  is  secured.  The  outline  of  the  apex  of  the 
heart  is  readily  mapped  out.  Over  the  tympanitic  stomach  light  per- 
cussion is  necessary.  To  narrow  the  area  of  percussion  about  the  apex, 
the  percussion  may  be  performed  on  the  larger  plate,  while  the  smaller 
is  applied  to  the  chest.  The  vibrations  over  the  liver  and  over  the 
right  ventricle  are  difficult  to  distinguish,  although  sometimes  so  differ- 
ent that  demarcation  of  the  ^border  of  the  ventricle  presents  no  diffi- 
culty. Between  the  apex  of  the  left  ventricle  and  the  left  lobe  of  the 
liver  the  space  is  easily  marked  out. 

A  correct  outline  of  the  heart  and  of  the  vessels  is  thus  obtained. 
The  upper  limit  of  dulness  is  formed  by  the  right  auricle,  the  aorta, 
and  the  pulmonary  artery.  Any  bulging  or  undue  expansion  is  due 
to  aneurism,  or  aneurismal  dilatation  of  the  aorta.  The  space  between 
the  apex  and  the  left  lobe  of  the  liver  defines  the  lower  border.  San- 
som  points  out  that  by  this  method  of  percussion  the  following  absolute 
data  can  be  obtained  :  "A  projection  to  the  right  of  the  area  of  the 
upper  part  over  the  second  and  third  interspaces  points  to  aneurism  of 
the  aorta  or  of  the  innominate  artery.  It  may  be  traced  to  the  left 
side  of  the  sternum  on  account  of  saccular  dilatation  of  the  aorta.  If 
the  dulness  at  the  upper  part  extend  greatly  to  the  left,  an  increase 
in  size  of  the  pulmonary  artery  may  be  suspected.  Along  the  mid- 
sternal  region,  extension  beyond  the  right  side  joining  the  line  indicat- 
ing the  upper  border  of  the  liver  indicates  distended  inferior  cava. 
This  distention  occurs  in  right-sided  dilatation  of  the  heart,  and  the 
dulness  may  also  be  due  to  dilatation  of  the  adjoining  auricle.  The 
outline  of  dulness  obtained  over  the  apex  of  the  heart,  if  pointed,  indi- 
cates hypertrophy  ;  a  more  rounded  outline  shows  dilatation.  In 
uncomplicated  hypertrophy  the  line  of  the  right  ventricle  forms  a 
much  less  obtuse  angle  with  the  liver-dulness  than  in  dilatation.  Of 
great  diagnostic  value  is  the  diminution  of  the  area  of  dulness  from 
atrophy  of  the  heart  as  observed  in  wasting,  as  in  cancer,  and  in  tuber- 
culosis ;  it  may  also  be  observed  in  typhoid  fever.  In  the  above- 
mentioned  conditions  it  is  a  bad  prognostic  sign." 

Adjacent  Dulness.  Care  must  be  taken  not  to  confound  the  dulness 
of  pleural  effusion  or  consolidated  lung  with  the  cardiac  dulness. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     367 

Repercussion.  Modification  of  the  vibrations  felt  by  the  fingers  on 
the  pleximeter,  as  pointed  out  by  Sansoni,  may  indicate  an  abnormal 
change  in  physical  condition  impossible  to  detect  in  any  other  way. 
It  is  to  be  remembered  that  over  the  lungs  the  vibrations  are  excessive ; 
over  solid  structures  they  are  modified  or  lessened.  Now,  the  change 
from  vibrations  to  absence  of  vibrations  may  be  gradual  or  abrupt. 
Sansom  determines  this  by  percussion,  after  the  heart  has  been  outlined 
in  the  above-mentioned  manner.  In  percussing  from  the  luug  and  the 
heart  area,  if  the  modified  vibrations  occur  abruptly,  it  is  very  prob- 
able that  there  is  pericarditis  with  effusion  or  thickened  pericardium. 
Or  if,  on  percussing  from  above  downward,  there  is  effusion  in  the 
pericardial  sac,  no  vibrations  are  to  be  elicited  over  the  area  delimited. 
That  is,  the  absence  of  vibrations  is  noted  over  the  whole  area  ; 
whereas,  in  ordinary  conditions,  when  the  pericardium  is  unaffected, 
in  percussing  from  above  downward  over  the  area  which  had  been 
delimited  on  the  right  and  left  sides  respectively,  a  line  will  be  reached 
where  the  vibrations  become  modified.  This  line  commences  a  little 
above  the  ensiform  cartilage  and  inclines  toward  the  left  border  of  the 
cardiac  dulness  at  the  level  of  the  fourth  rib  and  third  interspace. 
Vibrations  are  more  marked  above  than  below  the  line.  The  line  at 
which  the  lessened  vibrations  begin  points  out  the  commencement  of 
the  thick  wall  of  the  ventricles  ;  the  portion  above  (more  vibratory) 
indicates  the  position  of  the  right  auricle  and  vessels.  If  the  plexi- 
metric  percussion  is  employed,  areas  of  superficial  and  deep  dulness 
need  not  be  estimated. 

Apex-beat.  Whichever  method  of  percussion  is  employed,  it  will  be 
often  observed  that  the  spot  marked  by  inspection  and  palpation  as  the 
apex-beat  is  far  outside  of  the  left  border  of  cardiac  dulness.  In 
hypertrophy  of  the  left  ventricle  it  may  be  a  considerable  distance  to 
the  left.  In  dilatation  the  difference  is  not  so  marked.  The  percus- 
sion-lines are  made  when  the  heart  is  away  from  the  chest,  and  hence 
are  within  the  systolic  apex-beat. 

Method  of  Graphic  Record.  We  are  indebted  to  Sansom  and  Ewart 
for  a  method  of  recording  the  outlines  of  the  areas  of  dulness  and  the 
position  of  the  apex-beat  and  other  pulsations,  which  is  of  great  value 
for  class-demonstration,  and  for  permanent  records  to  compare  with 
other  records  taken  from  time  to  time.  The  points  of  pulsation  and 
border-lines  of  dulness  are  marked  by  a  dermatographic  pencil.  Vari- 
ous colors  may  be  used  in  order  to  indicate  the  different  data.  The 
landmarks,  etc.,  are  outlined  by  a  camel' s-hair  pencil  dipped  in  olive  oil. 
The  epistcrnal  notch,  the  clavicles,  the  intercostal  spaces,  the  ensiform 
cartilage  and  nipples,  etc.,  the  percussion-outlines,  and  other  recorded 
marks  are  passed  over  with  the  pencil.  A  sheet  of  tissue-paper,  or  of 
•copying-paper,  is  then  gently  placed  over  the  whole,  so  that  the  oil- 
marks  are  imprinted.  After  the  paper  is  removed,  the  oil-outline  is 
colored  with  the  dermatographic  pencil,  and  a  permanent  record  is  pre- 
served. By  this  plan  of  recording  a  maximum  of  precision  is  attained. 
Outlines  can  be  measured  and  positions  defined  by  mathematical  data. 
The  name  of  the  patient,  the  date  of  observation,  with  a  brief  history 
of  the  case,  should  be  attached  to  the  chart.     If  the  colored  pencil- 


368  SPECIAL  DIAGNOSIS. 

marks  on  the  patient's  chest  are  objectionable,  the  outline  may  be  made 
with  the  colorless  oil-pencil  at  the  various  steps  of  the  examination. 
After  they  are  transmitted  to  the  paper  they  may  be  made  more  distinct 
with  the  colored  pencils.  Packard  tits  to  the  chest  a  square  of  coarsely 
woven  muslin  and  outlines  the  ribs  and  sternum,  etc.,  which  are  seen 
through  the  meshes.  With  colored  pencils,  dull  areas,  etc.,  the  site 
of  organs,  the  position  of  murmurs,  are  then  designated. 

Ewart  has  shown  that  after  long  intervals  the  size  of  the  chest  and 
abdomen  is  apt  to  alter  from  various  circumstances — growth,  muscular 
development,  habit  of  sitting,  etc.  He  therefore  points  out  the  advisa- 
bility of  using  the  sternum,  which  is  immovable,  for  the  sake  of  future 
comparison. 

Sense  of  Resistance.  Ebstein  delimits  the  heart  by  the  sense 
of  resistance,  change  in  size  being  noted  by  increase  or  diminution  of 
the  area  which  in  health  gives  a  sense  of  resistance  to  the  percussing 
finger. 

Auscultation.  Method.  Either  method  of  auscultation  may  be 
employed  in  order  to  secure  data  by  the  sense  of  hearing.  By  the 
immediate  method  we  may  form  a  general  notion  as  to  the  condition 
of  the  heart-sounds.  The  mediate,  however,  is  preferable  because 
it  is  esseutial  to  localize  the  sounds  that  are  heard,  and  because,  if 
the  double  stethoscope  is  used,  we  can  percuss  the  cardiac  area.  The 
patient  should  be  in  a  comfortable  position.  The  muscles  should 
not  be  strained.  The  general  directions  for  performing  auscultation 
must  be  followed.  Before  he  begins  the  observer  has,  if  possible,  de- 
termined the  presence  of  the  impulse,  or  found  the  radial  or  carotid 
pulse.  By  this  means  the  time  of  the  heart  is  taken  and  the  relation 
of  the  events  of  the  cardiac  cycle  to  each  other  is  ascertained.  With 
each  impulse  or  carotid  pulse  a  systole  takes  place ;  hence  they  are 
synchronous.     The  systole  occurs  just  before  the  radial  pulse. 

The  time  occupied  by  the  systole  and  the  diastole  is  about  equal. 
The  systole  is  made  up  of  two  sub-events — contraction  of  the  auricle 
and  contraction  of  the  ventricle.  If  five-tenths  represent  the  length  of 
time  of  the  systole,  one-tenth  is  auricular  and  four-tenths  ventricular 
systole. 

The  Sounds  in  Health.  The  stethoscope  is  placed  over  the  base  of 
the  heart  at  about  the  fourth  interspace,  with  the  finger  on  the  impulse 
or  the  radial  pulse;  a  sound  will  be  noted  at  the  time  of  the  impulse 
or  the  systole,  followed  almost  immediately  by  another  sound  and  then 
a  period  of  silence.  The  sounds  that  attend  the  systole  are  known  as 
the  systolic,  or  first  sounds.  The  sounds  that  follow  are  known  as  the 
diastolic,  or  second,  sounds.  The  sounds  and  silence  mark  the  comple- 
tion of  a  cardiac  cycle  as  far  as  the  ear  is  concerned  (Fig.  68).  A 
definite  relationship  in  time  exists  in  the  cardiac  cycle.  Cause.  Four 
sounds  are  created  during  a  cycle,  one  at  each  valve.  The  sounds 
created  with  the  systole  (systolic  sounds)  are  due  to  contraction  of  the 
right  ventricle  and  closure  of  the  tricuspid  valve;  and  on  the  opposite 
side,  of  the  left  ventricle  and  the  mitral  valve.  The  rush  of  blood 
along  the  course  of  the  vessels  and  the  shock  of  the  heart  may  con- 
tribute somewhat  to  the  systolic  sound.     The  sounds  heard  in  the 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     369 

beginning  of  the  diastole  (diastolic  sounds)  are  due  to  closure  of  the 
aortic  and  pulmonary  valves.  They  are  due  to  the  tension  produced  on 
the  valves  as  the  respective  arteries  contract  upon  the  columns  of  blood. 
The  closures  of  the  valves  make  up  most,  if  not  all,  of  the  sounds. 
To  review:  two  sounds  occur  with  the  systole,  one  from  closure  of 
the  mitral,  another  from  closure  of  the  tricuspid  valve  ;  two  with  the 
diastole  from  closure  of  the  aortic  and  pulmonary  valves,  respectively. 


Diagrammatic  representation  of  the  movements  and  sounds  of  the  heart.  (After  Sharpey.)  This 
diagram  shows  merely  the  general  relations  of  the  several  events,  and  does  not  represent  exact 
measurements. 

In  a  heart  beating  seventy-two  times  a  minute  Foster  estimates  each  entire  cardiac  cycle  as 
occupying  about  0.8  sec.  ;  of  which  0.3  sec.  represents  the  duration  of  the  systole  of  the  ventricle 
0.4  sec.  the  diastole  of  both  auricle  and  ventricle,  or  the  "  passive  interval,"  and  0.1  sec.  the  systole 
of  the  auricle. 

Only  one  "pause  "  is  marked  here— sometimes  called  the  "  long  pause  ;  "  some  writers  describe 
a  "short  pause"  also— indicated  in  the  diagram  by  the  small  space  between  the  first  and  the 
second  sound. 

By  the  above  method,  the  first  essentials  in  auscultation  are  learned, 
viz. ,  to  associate  impulse  or  radial  pulse  with  the  heart-sounds,  and  to 
determine  the  relation  of  the  sounds  to  the  events  of  a  cardiac  cycle. 
In  this  manner  the  time  or  rhythm  of  the  heart  is  ascertained.  We 
further  differentiate  the  sounds  by  their  character,  their  position  of  maxi- 
mum intensity,  and  their  transmission. 

Character  of  the  Sounds.  The  systolic  sounds  are  prolonged,  some- 
what dull  in  character,  low  in  pitch,  and  resemble  the  sound  produced 
by  the  pronunciation  of  the  syllable  "  m66."  The  diastolic  sounds  are 
short,  sharp,  and  quick,  and  resemble  the  sound  produced  by  the  pro- 
nunciation of  the  syllable  "  dupp."  The  syllables  ubb,  dupp  indicate 
the  character  of  the  sounds  in  health.  Modifications  in  the  intensity 
of  the  sound  are  due  to  changes  in  the  tension  of  the  valve-curtains, 
and  are  dependent  upon  the  muscle.  If  it  is  strong,  the  valves  are 
made  more  tense.  Experiment  and  the  results  of  disease  have  aided  in 
proving  these  points. 

Position  of  maximum  intensity  and  direction  of  transmission.     The 

24 


370 


SPECIAL  DIAGNOSIS. 


sounds  produced  by  the  closure  of  the  valves  are  created,  as  the 
topography  of  the  heart  shows,  quite  near  to  each  other,  but  by  con- 
duction of  the  sound  they  are  transmitted  away  from  the  respective 
valves  in  particular  directions,  and  heard  loudest  in  definite  areas  on 
the  chest. 


Areas  of  cardiac  murmurs  (Gairdner  for  the  areas;  and  Luschka  for  the  anatomy).  The  out- 
lines of  organs,  which  are  partially  invisible  in  the  dissection,  are  indicated  by  very  fine  dotted 
lines ;  while  the  areas  of  propagation  of  valvular  murmurs,  as  described  in  the  text,  have  been 
roughly  marked  by  additional  much  coarser  and  more  visible  dotted  lines — the  character  of  the 
dots  being  different  in  each  of  the  four  areas.  A  capital  letter  marks  each  area,  viz. :  A,  the  circle 
of  mitral  murmurs  corresponding  with  the  left  apex ;  B,  the  irregular  space  indicating  the  ordi- 
nary limits  of  diffusion  of  aortic  murmurs,  corresponding  mainly  with  the  whole  sternum,  and 
extending  into  the  neck  along  the  course  of  the  arteries ;  C,  the  broad  and  somewhat  diffused 
area  occupied  by  tricuspid  murmurs,  and  corresponding  generally  with  the  right  ventricle ;  D, 
the  circumscribed  circular  area  over  which  pulmonic  murmurs  are  commonly  heard  loudest. 

Reference  letters :  r.  au.  =  right  auricle ;  a.  o.  =  arch  of  aorta ;  v.  i.  =  the  two  innominate  veins  ; 
v.  c.  =  vena  cava  descendens ;  p.  =  pulmonary  artery  ;  1.  au.  —  left  auricle ;  1.  v.  —  left  ventricle; 
r.  v.  —  right  ventricle.    (Finlayson.) 


A.  The  systolic  or  first  sounds.  Two"  sounds  are  created.  The  valves 
which  cause  the  sound  are  near  to  each  other.  (See  "Anatomy.")  Be- 
cause of  their  anatomical  relations  the  sounds  are  conducted  into  differ- 
ent areas,  by  virtue  of  which  they  are  differentiated.  The  Mitral  Area. 
The  sound  produced  by  the  closure  of  the  mitral  valve,  created  opposite 
the  fourth  interspace  near  the  sternum,  is  transmitted  to  the  surface  of 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     371 

the  chest  by  the  thickened  left  ventricle,  and  hence  is  heard  loudest 
where  that  is  nearest  the  chest,  namely,  at  the  apex.  The  Tricuspid 
Area.  The  sound  produced  by  the  closure  of  the  tricuspid  valve 
is  transmitted  by  the  right  ventricle  and  is  heard  loudest  over  the  lower 
portion  of  the  sternum.  Thus  it  is  seen  that  the  systolic,  or  first  sounds, 
are  heard  loudest  at  the  lower  portion  of  the  heart. 


Fig.  70. 


The  valve  areas. 
1.  Mitral  area.    2.  Tricuspid  area.    3.  Aortic  area. 


4.  Pulmonary  area. 


The  diastolic  or  second  sounds.  Two  sounds  are  created.  The  valves 
at  which  they  are  produced  are  also  in  close  proximity.  To  distinguish 
the  two  sounds  it  is  necessary  to  auscult  over  areas  into  which  they 
are  transmitted.  The  Aortic  Area.  The  sound  produced  by  the  closure 
of  the  aortic  valve  is  heard  loudest  at  the  second  costal  cartilage  on  the 
right,  because  the  aorta  which  conducts  the  sound  is  nearest  the  surface 
of  the  chest  at  this  point.  This  cartilage  is  known  as  the  aortic  carti- 
lage. The  Pulmonary  Area.  The  sound  produced  by  the  closure  of 
the  pulmonary  valve  is  conducted  to  the  left  and  heard  loudest  in  the 
second  interspace  near  the  left  edge  of  the  sternum.  It  is  seen  that 
the  diastolic  sounds  are  heard  at  the  base  of  the  heart  (see  Fig.  69). 

Differentiation.  To  distinguish  the  sounds  produced  by  the 
auriculo-ventricular  valves  (systolic)  from  the  valve-sounds  produced 
at  the  vessels  (diastolic),  we  observe,  first,  the  time;  second,  the  char- 
acter of  the  sound;  and,  third,  the  position  of  greatest  loudness  or 
maximum  intensity  and  direction  of  transmission. 

1.  The  Time,  (a)  In  relation  to  impulse  the  first  sounds  are  systolic 
in  time.  They  occur  at  the  same  time  as  the  impulse  and  carotid 
pulse,  and  they  precede  slightly  the  radial  pulse.  The  second  sounds 
are  diastolic  and  follow  the  pulse,  (b)  In  relation  to  the  events  of  the 
cardiac  cycle.  The  systolic  sounds  are  followed  by  a  short  silence  and 
preceded  by  a  long  silence.  The  second  sounds  practically  follow  the 
first  and  precede  the  long  silence. 

2.  The  Character.  The  first  sounds  are  low  in  pitch,  dull  and  pro- 
longed ;  the  second  sounds  are  high  in  pitch,  short  and  sharp. 


372  SPECIAL  DIAGNOSIS. 

3.  Position  of  maximum  intensity  and  direction  of  transmission. 
The  first  sounds  are  heard  loudest  at  the  apex  of  the  heart  and  at  the 
base  of  the  sternum,  and  are  transmitted  toward  the  axillae.  They 
may  be  heard  all  over  the  cardiac  area,  but  the  position  of  maximum 
intensity  is  in  the  lower  portion  and  toward  the  left.  The  second 
sounds  are  loudest  at  the  base  of  the  heart.  They  may  be  propagated 
beyond  the  prsecordia  toward  the  neck,  and  be  heard  loudest  in  the 
vessels  of  the  neck. 

Differentiation  of  Each  Sound.  1.  Mitral  first  or  systolic 
sound,  heard  loudest  at  the  apex,  inward  to  the  parasternal  line,  upward 
to  the  third  interspace.  2.  Tricuspid  first  or  systolic  sound,  heard 
loudest  at  the  lower  part  of  the  sternum  and  toward  the  left  to  the 
parasternal  line  as  high  as  the  third  rib.  3.  Aortic  second  or  diastolic 
sound,  heard  loudest  at  the  aortic  cartilage,  propagated  into  the  ves- 
sels of  the  neck,  and  also  heard  at  and  outside  of  the  apex-beat.  It 
is  louder  than  the  pulmonary  second  sound  in  health.  4.  Pulmonary 
second  or  diastolic  sound,  localized  to  the  second  interspace  and  the 
third  rib. 

Modifications  of  the  Sounds.  All  of  the  sounds  or  one  or 
more  of  the  four  sounds  may  be  increased  or  diminished  in  intensity 
or  accentuation. 

All  Sounds  Increased,  a.  Causes  outside  of  the  pericardium.  1. 
Auything  which  brings  the  heart  closer  to  the  ear  of  the  observer. 
Thus,  in  patients  with  thin  chest-walls,  when  the  heart  is  pushed  to 
the  surface  of  the  chest  (mediastinal  tumor)  or  the  lung  removed  (pleural 
contraction).  2.  Anything  which  conducts  the  sounds,  as  consoli- 
dated lung  in  the  vicinity,  or  a  pneumothorax,  or  pulmonary  cavities. 
b.  Affections  of  the  pericardium,  as  pericardial  adhesions,  c.  Condi- 
tions of  the  heart.  1.  Hypertrophy.  2.  Overaction,  as  in  palpitation, 
fevers,  anaemia,  exophthalmic  goitre. 

All  Sounds  Weakened,  a.  Causes  outside  of  the  pericardium.  1. 
General  exhaustion.  2.  Thick  chest- walls,  large  mammary  gland. 
3.  Emphysema  of  the  lungs  overlapping  the  heart,  b.  Affections  of 
the  pericardium,  as  fluid  or  air  in  the  pericardial  sac.  c.  Conditions 
of  the  heart.      Atrophy;  myocarditis;  some  cases  of  dilatation. 

In  short,  loudness  of  all  the  sounds  occurs  from  (a)  conditions  outside 
of  the  heart :  heart  nearer  chest- wall,  consolidation  of  lungs,  cavities; 
(b)  conditions  of  the  heart  itself  ;  hypertrophy;  overaction.  Weakness 
of  the  sound  occurs  from — (a)  conditions  outside  of  the  heart:  thick 
chest-walls,  emphysema,  general  exhaustion;  (6)  affectious  of  the  peri- 
cardium :  effusions;  (c)  affections  of  the  heart:  atrophy;  dilatation; 
myocarditis. 

Changes  of  Individual  Sounds.  The  above  applies  to  all  the 
sounds.  Increase  or  diminution  of  the  systolic  or  of  the  diastolic 
sounds,  or  of  any  one  of  the  four  sounds,  may  be  present. 

Increase  in  Loudness  of  the  First  Sound.  Increased  loudness  of  the 
first  sound  is  noted  when  the  muscle  is  hypertrophied,  and  the  tension 
on  the  valves  thereby  increased.  In  hypertrophy  of  the  left  ventricle 
the  increase  is  most  marked.  The  sound  is  duller  and  has  a  prolonga- 
tion which  is  very  characteristic.     In  hypertrophy  of  the  right  ventricle 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     373 


the  sound  is  dull  aud  prolonged  over  the  sternum,  but  not  to  the  same 
degree  as  when  the  left  is  hypertrophied. 

Increase  in  Loudness  of  the  Diastolic  Sound.  Either  of  the  second, 
or  diastolic,  sounds  may  be  increased  in  loudness  or  accentuated. 

Accentuation  of  the  Aortic  Diastolic  Sound.  Anything  which  causes 
increased  tension  in  the  aortic  circulation,  and  hence  increased  contrac- 
tile force  of  the  aorta,  will  increase  the  intensity  or  accentuation  of  the 
second  sound.     In  hypertrophy  of  the  heart  the  aortic  sound  is  accen- 


Fig.  71. 


A 


Normal  first  Accentuated 

and  second  sounds,     first  sound. 

tuated  because  there  is  corresponding  increased  contraction  of  the  aorta, 
following  the  forcible  expulsion  of  the  blood  from  the  ventricle.  In- 
crease in  arterial  tension  is  also  due  to  increased  contraction  of  the 
aorta  when  there  is  peripheral  resistance  to  the  outflow  of  blood.  It 
is  associated  with  the  following  conditions  which  cause  accentuation 
of  the  second  sound:  Atheroma  of  the  aorta,  or  of  the  arteries  in 
general;  aneurism  of  the  aorta;  disease  of  the  kidneys,  and  particu- 
larly in  that  form  in  which  there  are  also  general  arterial  changes, 
namely,  chronic  interstitial  nephritis.  It  is  true  that  the  accentuation 
may  be  partly  due  to  the  hypertrophy  of  the  heart  which  coexists. 

Accentuation  of  the  aortic  second  sound  occurs  independently  of 
permanent  change  in  the  arteries.  If  for  any  reason  there  is  spasm 
of  the  peripheral  capillaries,  as  from  a  chill,  from  epilepsy,  from  ner- 
vousness due  to  hysteria,  tension  in  the  arteries  is  heightened,  and  hence 
the  second  sound  accentuated.  It  is  seen  that  accentuation  of  the  second 
sound  is,  therefore,  a  marked  index  of  the  state  of  the  vascular  system 
in  general;  it  is  not  an  evidence  of  disease  of  the  heart  alone.  In 
certain  fevers  aud  in  states  of  the  blood  in  which  the  vasomotor  nerves 
are  irritated,  causing  peripheral  contraction,  as  in  scarlatina,  accentu- 


FlG.  72. 


Normal  first  and 
second  sounds. 


Accentuated 
second  sound. 


ation  of  the  second  sound  is  observed,  often  before  the  development  of 
local  inflammatory  diseases  due  to  the,same  cause,  as  nephritis  in  scar- 
latina. The  occurrence  of  this  complication  may  be  suspected  when 
accentuation  of  the  aortic  second  sound  is  heard. 

Accentuation  of  the  Pulmonary  Diastolic,  or  Second  Sound.  This  is 
due  to  the  same  physical  condition  which  causes  accentuation  of  the 
aortic  second  sound.  Anything  which  heightens  the  tension  in  the 
pulmonary  artery  will  cause  increased  loudness.      In  health   the  pul- 


374  SPECIAL  DIAGNOSIS. 

nionary  second  is  not  so  loud  as  the  corresponding  aortic  sound.  If, 
therefore,  we  find  in  the  second  or  third  left  interspace  the  sound  as 
loud  as  an  aortic  sound,  or  louder,  it  can  be  said  that  the  pulmonary 
second  sound  is  accentuated.  It  is  due  :  1.  To  any  condition  which 
causes  congestion  within  the  lungs,  the  right  ventricle  being  at  the 
same  time  of  normal  or  increased  strength.  It  is  heard  in  the  early 
stages  of  pneumonia,  and,  if  the  course  of  the  disease  continues  favor- 
able, may  remain  accentuated  to  the  end.  If,  on  the  other  hand,  the 
circulation  is  embarrassed,  and  the  right  heart  is  failing,  it  will  become 
fainter,  and  may  be  scarcely  recognizable.  Such  change  in  the  sound 
accompanies  increase  of  respiratory  distress,  and  indicates  that  the 
right  heart  is  becoming  exhausted.  It  is,  therefore,  an  ominous  sign  in 
acute  pulmonary  disease.  If  the  case  is  unfavorable,  the  signs  of  right - 
sided  dilatation  will  subsequently  occur.  2.  It  occurs  in  emphysema  of 
the  lungs.  Notwithstanding  the  covering  of  the  heart  by  the  lung,  the 
sound  can  be  heard,  and  may  be  the  only  one  of  the  four  sounds  which 
can  be  distinguished.  3.  In  valvular  disease  of  the  heart  seated  at  the 
mitral  orifice  accentuation  of  the  pulmonary  second  sound  is  heard,  due 
to  increased  tension  in  the  pulmonary  artery.  In  mitral  obstruction  the 
blood  is  retained  in  the  auricle  and  pulmonary  veins,  causing  a  resistance 
to  the  force  of  the  right  ventricle.  Increased  tension  in  the  pulmonary 
artery  is  the  result,  with  exaggerated  strain  upon  the  valves.  In  mitral 
regurgitation,  with  the  systole  the  blood  is  thrown  back  into  the  auricle, 
and  consequently  meets  with  blood  coming  from  the  lungs.  This  in 
time  increases  the  amount  of  blood  aud  of  blood-pressure  in  the  pul- 
monary artery.  A  heightened  tension  results.  Skoda  pointed  out  the 
significance  of  this  association.  Sometimes  in  doubtful  cases,  either 
in  the  presence  or  absence  of  a  murmur  at  the  mitral  orifice,  the  occur- 
rence of  this  sign  makes  it  more  than  probable  that  there  is  mitral 
valvulitis. 

Feebleness  of  the  Mitral  Sound.  Feebleness  of  the  mitral  sound 
observed  at  the  apex  of  the  heart  may  be  an  indication  of  weakness  of 
the  muscle  from  dilatation,  atrophy,  or  myocarditis.  It  must  be 
remembered,  however,  that  weakness  of  the  ventricle  is  not  attended 
by  enfeeblement  of  sound  alone,  but  that  when  the  right  or  left  ven- 
tricle is  weakened  the  duration  of  the  sound  is  lessened.  The  loud- 
ness remains  the  same,  or  may  be  increased.  Xote,  then,  that  a  short 
systolic  sound,  loud,  sharp,  flapping,  sometimes  reverberating,  heard 
at  the  apex,  indicates  dilatation  or  feebleness.  The  tension  of  the  ven- 
tricles and  valves  creating  the  sound  is  increased  by  internal  pressure. 
The  svstolic  sounds  become  like  the  diastolic,  and  mav  be  distinguished 
by  the  ear  with  difficulty;  but  if  the  time  is  taken  with  the  finger  on 
the  apex-beat  or  carotid  artery,  if  the  heart's  action  is  slow  the  distinc- 
tion can  readily  be  made. 

Diminished  Accentuation  or  Weakness  of  the  Aortic  Sound.  This  is 
an  indication  of  cardiac  weakness,  and  is  apt  to  ensue  in  the  course  of 
fevers  when  exhaustion  takes  place.  It  is  a  sign  of  myocarditis  and 
of  degeneration  of  the  muscular  walls  of  the  heart.  Under  these 
circumstances  the  systole  of  the  ventricle  is  also  weakened. 

Feebleness  of  the  aortic  second  sound,  with  hypertrophy  aud  hence 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     375 

strong  contraction  of  the  ventricle,  occurs  when  the  aortic  leaflets  are 
swollen  or  enlarged  and  thickened.  This  condition  of  the  valves  is 
due  to  atheroma,  and  is  in  all  probability  associated  with  atheroma  of 
adjacent  vessels,  as  the  coronary  arteries.  It  is,  therefore,  a  sign  of 
serious  importance. 

Diminished  Accentuation  or  Feebleness  of  the  Pulmonary  Sound.  This 
is  of  importance  in  the  course  of  valvular  disease  of  the  heart,  pro- 
viding previous  accentuation  has  been  observed.     If  the  marked  loud- 


FlG.  73. 


II 


Normal  first  and       Diminished 
second  sounds.         first  sound. 

ness  gives  way  to  feebleness,  there  is  strong  probability  that  the  right 
heart  is  undergoing  dilatation  with  regurgitation  at  the  tricuspid  orifice. 
While  accentuation  of  the  pulmonary  second  sound  in  valvular  disease 
is  of  good  omen,  enfeeblement  of  the  sound  is  of  bad  prognostic  omen, 
indicating  weakness  of  the  right  veutricle. 

Alterations  in  the  Rhythm.  Fcetal  rhythm  of  the  heart :  Em- 
bryocardia — a  term  first  used  by  Huchard  to  designate  a  condition  in 
which  the  pause  between  the  heart- sounds  is  of  equal  length.  The 
first  and  second  sounds  are  exactly  alike,  resembling  the  beat  of  the  foetal 
heart.  The  sign  is  of  importance  in  prognosis.  In  acute  disease  and 
in  fever  it  indicates  enfeeblement  of  the  heart  and  reduction  of  arterial 
tension.  In  the  later  stages  of  Graves'  disease  it  is  a  forerunner  of 
death.  It  is  distinguished  from  the  rapid  beat  of  the  heart  in  tachy- 
cardia by  the  fact  that  in  the  latter  condition  the  normal  rhythm  is  pre- 
served. 

Cantering  Rhythm  of  the  Heart.  The  ear  recognizes  three  sounds. 
The  usual  sounds  may  or  may  not  be  attended  by  murmur,  and  the 
interpolated  sound  may  be  dull,  or  short  and  sudden.  It  may  occur  at 
various  periods  in  the  cardiac  cycle,  either  before  the  systolic  sound, 
after  the  diastolic  sound,  or  during  the  diastolic  pause.  The  rhythm 
recalls  the  sound  of  a  horse  cantering.  It  was  termed  by  Bouillaud 
the  bruit  de  galop.  When  the  interpolated  sound  resembles  the  first 
or  second  it  is  similar  to  reduplication  of  the  sounds.  It  has  been 
observed  in  hypertrophy  of  the  heart,  especially  of  the  left  ventricle; 
dilatation  of  the  heart ;  in  adherent  pericardium,  with  dilated  hyper- 
trophy ;  in  myocarditis,  in  the  course  of  fevers  ;  and  in  excessive 
anaemia.  It  is  heard  loudest  over  the  right  and  left  ventricles.  Potain 
thinks  it  is  due  to  tension  communicated  to  the  wall  of  the  ventricle 
by  the  entrance  of  blood  into  its  cavity,  aud  is  more  marked  when  the 
wall  is  least  extensible,  as  in  hypertrophy  on  the  one  hand  or  ex- 
haustion of  the  muscle;  in  either  of  the  two  the  walls  vibrate  more 
readily.  The  triple  rhythm  is  of  bad  prognostic  omen  in  chronic 
Bright' s  disease. 

Reduplication  of  the  Sounds.  Reduplication,  or  apparent  doubling 
of  the  heart-sounds,  occurs  in  various  forms.     In  health  the  systolic 


376  SPECIAL  DIAGNOSIS. 

sounds  are  created  synchronously  ;  a  fraction  of  a  second,  not  appre- 
ciated by  the  ear,  separates  the  diastolic  sounds.  In  so-called  redupli- 
cation one  systolic  sound  may  follow  the  other,  or  the  aortic  and  pul- 
monary diastolic  sounds  may  be  created  at  distinct  intervals.  As  has 
been  stated,  in  galloping  rhythm  the  idea  of  reduplication  is  sometimes 
transmitted  to  the  ear.  Reduplication  may  take  place  in  health  under 
the  influence  of  respiratory  movements.  The  systolic  sounds  may  be 
doubled  at  the  end  of  expiration  and  the  commencement  of  inspiration, 
while  the  diastolic  sounds  are  doubled  at  the  end  of  inspiration  and  the 
commencement  of  expiration.  In  mitral  disease  reduplication,  or  want 
of  synchronous  closure  of  the  two  valves,  is  of  frequent  occurrence. 
The  heart-sounds  are  doubled  and  heard  over  the  base  of  the  heart. 
Reduplication  of  the  systolic  sounds  occurs  in  chronic  Bright' s  disease. 
Reduplication,  or  Doubling  of  the  Systolic  Sounds,  is  heard  over  the 
apex  or  the  right  ventricle.  Several  explanations  have  been  giveu  for 
the  cause  of  the  reduplication.  At  first  it  was  thought  to  be  due  to 
want  of  synchronism  in  the  action  of  the  ventricles — that  one  ventricle 
contracted  before  the  other,  due  to  the  fact,  of  course,  that  the  pres- 
ence of  blood  stimulates  one,  but  not  the  other.  By  Hayden  it  was 
thought  that  reduplication  of  the  first  sound  was  due  to  the  two  major 
elements  of  the  sound  acting  asynchronously,  the  muscular  sound  taking 


Fig.  74. 


(VI      n 


a. 

b. 

formal  first  and 

Reduplicated 

second  sounds. 

first  sound. 

place  before  the  sound  produced  by  the  tension  of  the  valves.  Dr. 
George  Johnson  took  the  view  that  the  reduplication  was  due  to  the 
contraction  of  the  auricle  and  ventricle;  that  the  sound  produced  by  the 
former  was  heard  on  account  of  hypertrophy  of  the  auricle,  and  heard 
first  because  of  the  natural  order  of  precedence.  Thus  far  the  reasons 
for  each  view  have  not  been  fully  established. 

Sansom  believes  that  reduplication  of  the  first  sound  is  due  to  the 
shock  communicated  to  the  contents  of  the  ventricle  just  before  systole — 
that  is,  during  the  auricular-systolic  period;  in  other  words,  it  is  due 
to  the  indirect  effect  of  the  auricular  systole.  The  contraction  of  the 
auricle  makes  tense  the  auriculo- ventricular  valve  of  the  left  side.  If 
it  occurs  late  in  the  diastole,  or  just  before  the  systole,  reduplication  of 
the  first  sound  is  caused;  if  early  in  the  diastole,  reduplication  of  the 
second  sound  is  created. 

Reduplication  of  the  Diastolic,  or  Second  Sounds.  While  held  by 
some  authorities  to  occur  in  a  large  proportion  of  healthy  individuals 
at  the  end  of  inspiration  and  the  commencement  of  expiration,  other 
observers,  equally  careful,  think  that  it  is  extremely  rare.  It  is  of 
frequent  occurrence  in  the  patients  of  the  Philadelphia  Hospital. 
This  is  no  doubt  due  to  the  fact  that  so  many  of  the  inmates  are  the 
subjects  of  all  forms  of  lung  disease,  or  disease  of  the  vascular  system, 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     377 

with  muscular  degeneration  of  the  heart,  that  the  equability  of  the 
pulmonic  circulation  is  disturbed.  There  is  no  doubt  that  it  can  be 
modified  or  induced  by  inspiration.  It  is  usually  heard  at  the  end  of 
inspiration  and  commencement  of  expiration.  Actual  reduplication  of 
the  second  sound  occurs  when  the  normal  asynchronism  of  the  closure 
of  the  aortic  and  pulmonary  valves  is  exaggerated.  It  has  been  found 
that  the  valve  of  the  pulmonary  artery  closes  a  fraction  of  a  second 
after  the  aortic  valve.  The  ear  usually  fails  to  appreciate  the  differ- 
ence unless  there  are  differences  of  blood-pressure;  when  doubled,  and 
therefore  appreciated,  it  is  indicative  of  a  difference  in  blood-pressure 
between  the  two  sides  of  the  circulation.  Increased  resistance  in  either 
will  lead  to  increased  tension,  quickened  recoil,  and  hence  quickened 
closure  of  the  valve.  The  conditions  that  are  associated  with  the 
doubling  of  the  second  sound  are  (1)  and  most  frequently,  mitral 
stenosis;  (2)  obstruction  of  the  circulation  in  the  lung — tuberculosis, 
emphysema,  and  broncho-pneumonia;  (3)  dilatation  of  the  right  ven- 
tricle ;  (4)  myocarditis.  The  sound  is  heard  at  the  second  and  third 
costal  cartilages  along  the  left  edge  of  the  sternum.  It  is  frequently 
heard  at  the  fourth  and  fifth  cartilages  on  the  left  side.  In  cases  of 
mitral  stenosis  it  is  heard  near  the  apex. 


0. 


Fig.  75. 


a.  6. 

Normal  first  and  Reduplicated  and 

second  sounds.         accentuated  second  sound. 
Illustrating  diagramatically  modifications  of  the  heart-sounds.    (Gibson  and  Russell.) 

Simulated  doubling,  or  false  reduplication,  is  a  sound  produced  at 
the  mitral  orifice.  It  is  difficult  to  tell  it  from  true  doubling  or  re- 
duplication. It  is  most  distinct  at  the  base  of  the  heart  along  the  left 
edge  of  the  sternum.  Occasionally  it  is  more  distinct  near  the  apex 
than  elsewhere.  It  occurs  with  the  conditions  found  in  true  doubling 
and  in  mitral  obstruction.  Cause.  Sansom,  Cheadle,  and  others  dis- 
tinctly point  out  that  this  double  second  sound  is  of  frequent  occur- 
rence, and  that  it  is  heard  most  frequently  at  the  apex.  Sausom  thinks 
that  the  cause  for  simulated  doubling  of  the  second  sound  is  the  same 
as  for  doubling  of  the  first.  There  is,  first,  the  normal  second  sound; 
second,  a  tension  of  the  mitral  curtain  producing  the  second  simulated 
sound.  This  tension  is  due  to  the  shock  of  the  blood  coming  from 
the  auricle  to  the  ventricle. 

Abnormal  Sounds.  Abnormal  sounds  may  be  heard  over  the  heart 
in  addition  to,  or  replacing  the  normal  sounds.  These  sounds  are  pro- 
duced in  the  heart,  the  bloodvessels,  or  in  the  pericardium.  They  are 
divided  into  friction-sounds  and  murmurs.  They  are  recognized  be- 
cause they  are  a  departure  from  the  normal  sounds  or  because  they  are 
superadded  sounds. 

Abnormal  Sounds  in  the  Pericardium.  They  arc  known  as 
friction-sounds,  and  splashing  or  bubbling  sounds.     The  former  occur 


378  SPECIAL   DIAGNOSIS. 

in  the  first  stage  of  pericarditis,  and  are  due  to  the  rubbing  together  of 
the  inflamed  surfaces,  either  the  congested,  vascular  pericardium,  or  the 
membrane  bathed  in  exudation,  or  covered  by  lymph.  The  friction- 
sound  is  recognized  by  (1)  its  character,  (2)  time,  (3)  position,  (4)  trans- 
mission, (5)  movability,  (6)  modification  by  position  of  patient,  pressure, 
course  of  disease,  etc.  1 .  The  pericardial  friction  is  usually  of  a  to-and- 
fro  character,  and  can  be  recoguized  as  distinct  from  the  heart-sounds. 
It  resembles  the  rubbing  or  scraping  together  of  two  roughened  surfaces. 
2.  It  is  not  necessarily  synchronous  with  each  sound.  It  is  a  to-and-fro 
sound,  systolic  and  diastolic  in  time.  It  may,  however,  be  only  systolic 
or  only  diastolic.  3.  It  is  heard  over  the  body  of  the  heart,  usually  in 
the  third  and  fourth  interspaces,  or  even  over  the  right  ventricle.  4.  It 
is  not  transmitted  away  from  the  heart.  Its  location  may  shift  from  day 
to  day  in  the  precordial  area.  5.  It  may  be  modified  by  pressure  or  by 
respiratory  movement;  or  be  influenced  by  the  position  of  the  patient. 
It  may  disappear  entirely  in  the  upright  posture.  An  impression  of 
nearness  to  the  ear  is  given  by  the  sound  observed  in  the  first  stage  of 
pericarditis.  'It  may  be  increased  or  lessened  in  loudness  by  a  deep 
inspiration.  It  disappears  during  the  period  of  effusion,  to  return 
after  that  is  absorbed. 

Diagnosis.  It  must  be  distinguished  from  the  pleural  friction, 
which  disappears  if  the  patient  is  asked  to  hold  his  breath.  The 
pericardial  friction  is  of  cardiac  rhythm,  the  pleural  friction  of  respi- 
ratory rhythm.  It  must  also  be  distinguished  from  the  so-called 
exocardial  friction-sounds.  The  pleura  adjacent  to  the  pericardium 
may  be  inflamed.  With  each  beat  of  the  heart  the  rough  surfaces  of 
the  pleura  are  agitated  and  generate  a  friction.  It  is  seated  along  the 
edges  of  the  right  auricle  or  left  ventricle.  It  is  systolic  in  rhythm, 
but  has  the  special  characteristic  that  it  is  modified  by  respiration. 
It  may  be  arrested  if  the  patient  holds  his  breath.  It  is  increased 
by  inspiration,  or  diminished  in  expiration  when  the  lungs  recede  from 
the  heart  in  expiration.  The  pericardial  friction  must  be  distinguished 
from  the  crepitations  and  rales  of  cardiac  rhythm  produced  by  the  im- 
pact of  the  heart  against  the  lung.  They  disappear  when  the  breath 
is  held.  The  distinctions  between  pericardial  frictions  and  cardiac 
murmurs  will  be  considered  later. 

Splashing  sounds  are  heard  when  there  are  air  and  fluid  in  the  peri- 
cardium. They  may  be  bubbling  or  gurgling  or  resemble  the  souud 
of  a  water-wheel.     They  continue  when  the  breath  is  held. 

Abnormal  Sounds  in  the  Heart  and  Vessels.  Murmurs.  If 
the  student  listens  with  the  stethoscope  over  a  large  superficial  vessel, 
and  does  not  employ  pressure,  he  will  not  detect  any  sound.  Tf,  how- 
ever, pressure  is  employed,  a  sound  or  murmur  is  produced.  The 
passage  of  the  blood  through  the  vessel  produces  no  sound  because  the 
vessel  or  tube  is  of  equal  calibre.  The  pressure  of  the  stethoscope 
alters  the  calibre  and  compels  the  fluid  to  pass  through  a  narrow  orifice 
into  a  wider  space.  In  this  manner  a  fluid  vein  is  produced.  The 
vibration  of  the  molecules  of  the  agitated  fluid  vein  produces  a  sound 
or  murmur.  The  loudness  of  the  sound  depends  upon  the  swiftness 
of  the  flow.     The  sound  in  this  instance  is  carried  in  the  direction 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     379 

of  the  blood-current,  hence  the  murmur  is  known  as  an  onward 
murmur. 

The  reverse  may  take  place.  The  fluid  may  flow  backward  from  a 
wider  into  a  narrower  space  without  the  production  of  sound;  if,  how- 
ever, the  fluid  breaks  on  bevelled  edges,  as  the  leaflets  of  heart-valves 
projecting  into  the  current,  the  fluid  is  again  thrown  into  vibration  and 
produces  noise.  If  there  is  considerable  constriction  by  the  bevelled 
edge,  the  sound  is  carried  farthest  against  the  natural  flow  of  the  fluid 
— hence  the  term  backward  murmur.  Some  authors  hold  that  mur- 
murs are  also  due  to  lateral  vibrations  of  the  walls  of  the  heart  or 
of  the  vessels.  Some  murmurs  may  resemble  tones,  and  are  called 
musical  murmurs.  Such  murmurs  are  due  either  to  the  vibrations  of 
the  solids  set  up  by  the  vibrating  fluid  vein,  or  to  the  vibrations  of  the 
fluid  vein  alone. 

Murmurs  are  divided  into  two  classes,  in  accordance  with  their  seat 
of  development.  Murmurs  originating  in  the  heart  are  known  as 
cardiac  murmurs.  Murmurs  originating  in  the  bloodvessels  are  vas- 
cular murmurs.  (See  p.  401.)  Cardiac  and  vascular  murmurs  are 
divided  into  (1)  organic  murmurs,  if  due  to  anatomical  changes  of  the 
heart  or  vessels  ;  (2)  inorganic,  functional,  or  hcernic,  if  due  to  changes 
in  the  quality  of  the  blood.  (See  p.  385.)  Cardiac  murmurs  are 
always  generated  at  the  orifices.  The  orifices  are  valvular  and  non- 
valvular. 

Valvular  Orifices.  The  valvular  orifices  and  their  anatomical  rela- 
tions have  been  described.  Murmurs  are  produced  at  these  orifices 
when  they  are  open  or  when  naturally  they  should  be  closed.  If  the 
murmur  is  produced  when  the  orifice  is  open,  it  is  because  there  is  nar- 
rowing of  the  orifice  or  dilatation  of  the  cavity  (relative  narrowing). 
The  murmur  is  always  produced  with  the  natural  current  of  blood, 
and  hence  is  known  as  an  onward  or  obstructive  murmur.  It  always 
or  nearly  always  implies  organic  disease  at  the  valve-orifice,  hsemic 
murmurs  excluded.  If  the  murmur  is  produced  when  the  orifice  should 
be  closed,  and  hence  when  the  valve  leaks,  it  is  because  the  valves  are 
diseased  and  cannot  shut  the  orifice,  or  because  they  are  too  small 
— incompetent — to  shut  it.  Such  murmurs  are  produced  against  the 
natural  current  of  blood,  and  are  known  as  backward  or  regurgitant 
murmurs. 

Non-valvular  Orifices.  The  orifices  of  the  vena  cava?  and  of  the 
pulmonary  veins,  and  of  the  perforations  of  the  septa  in  congenital 
heart  disease  are  non-valvular.  They  are  at  times  the  seat  of  murmurs 
— as  in  open  foramen  ovale  or  perforated  ventricular  septum. 

Diagnosis  of  Murmurs.  The  student  lias  learned  that  an  abnor- 
mal sound  or  a  murmur  is  present.  It  is  necessary  then  to  determine, 
first,  at  which  orifice  the  murmur  is  produced  (the  seat  of  the  mur- 
mur) and,  second,  the  nature  of  the  murmur — obstructive  or  regurgi- 
tant. Murmurs  are  therefore  studied  as  heart-sounds  are  studied,  as  to 
their  seat  or  location,  their  time,  and  the  direction  of  their  transmission. 
The  location  of  the  murmur  indicates  which  valve-orifice  is  affected; 
the  time  and  the  direction  of  transmission  the  nature  of  tiie  murmur. 

1.   The  Orifice  Affected.      The  Seat  of  the  Murmur.     We  are 


380  SPECIAL  DIAGNOSIS 

enabled  accurately  to  determine  the  site  of  the  murmur  by  noting  its 
position  of  maximum  intensity  and  the  direction  of  its  transmission. 

The  Position  of  Maximum  Intensity.  The  point  of  maximum  inten- 
sity of  a  murmur  corresponds  to  the  area  at  which  the  normal  sound 
of  the  respective  valve  is  heard  loudest.  It  may  be  remembered  that 
the  cardiac  orifices  are  closely  situated,  and  that,  therefore,  the  murmurs 
must  be  generated  within  a  small  area,  so  small  that  it  would  be  im- 
possible to  ascertain  at  which  valve-orifice  the  murmur  is  created,  were 
it  not  for  the  fact  that  under  the  laws  of  conduction  of  sound  the  mur- 
murs are  conducted  away  from  their  point  of  origin  to  certain  definite 
stations  where  in  health  the  respective  valve-sound  is  heard  loudest. 

1.  Murmurs  at  the  Apex — the  Mitral  Area.  The  murmur  is  heard 
loudest,  or  with  the  greatest  intensity,  at  the  apex.  It  is  created  at 
the  mitral  orifice,  but  is  conducted  to  the  apex  by  the  left  ventricle 
which  is  nearest  the  chest- wall  at  this  point.  The  solid  muscle  of  the 
ventricle  conducts  the  sound  generated  at  this  valve  (see  1,  Fig.  70). 

2.  Murmurs  at  the  Xiphoid  Cartilage  or  the  Tricuspid  Area.  The 
murmur  is  heard  loudest  at  the  xiphoid  cartilage  or  the  head  of  the 
fourth  or  fifth  rib.  It  is  created  at  the  tricuspid  orifice,  and  is  heard 
most  distinctly  over  the  lower  portion  of  the  sternum,  and  along  the  left 
edge,  because  the  right  ventricle  is  in  apposition  with  the  chest-wall  at 
this  spot  (see  2,  Fig.  70). 

3.  Murmurs  at  the  Second  Costal  Cartilage  or  Second  Interspace  on 
the  Bight — the  Aortic  Area.  When  a  murmur  is  heard  with  greatest 
intensity  at  this  point  it  is  usually  generated  at  the  aortic  orifice,  and 
is  conducted  to  this  region  by  the  aorta,  which  comes  nearest  to  the 
surface  of  the  chest  at  this  point  (see  3,  Fig.  70). 

4.  Murmurs  in  the  Second  Left  Interspace — the  Pulmonic  Area.  A 
murmur  heard  loudest  at  the  second  interspace  along  the  left  edge  of 
the  sternum  is  generated  at  the  pulmonary  orifice  ;  it  is  heard  loudest  in 
this  area  because  the  pulmonary  artery  is  nearest  the  chest  at  this  point. 

The  Direction  of  Transmission.  This  will  be  considered  later, 
although  we  may  say  that  systolic  murmurs  due  to  disease  of  the  aortic 
valve  are  transmitted  upward  from  the  base,  while  systolic  murmurs 
due  to  disease  of  the  mitral  valve  are  transmitted  away  from  the  apex 
and  toward  the  axilla. 

2.  The  Nature  of  the  Murmur.  Having  determined  the  point 
of  maximum  intensity  of  the  murmur,  hence  the  valve  which  is 
probably  the  seat  of  the  disease,  we  next  wish  to  determine  the  nature 
of  the  murmur.  The  physical  conditions  which  produce  murmurs 
are  present  both  during  the  time  when  the  valves  should  be  closed 
and  also  during  the  time  when  the  valves  are  open  and  the~blood  is 
flowing  through  the  orifices.  A  murmur  which  is  produced  at  orifices 
which  should  be  closed,  the  valve  permitting  blood  to  flow  back  through 
the  orifice,  is  known  as  the  murmur  of  regurgitation.  A  murmur  that 
occurs  at  the  time  that  the  blood  should  in  health  be  passing  through  an 
orifice,  is  known  as  a  murmur  of  obstruction.  We  have  to  determine 
whether  the  murmur  at  an  orifice  is  due  to  regurgitation  or  to  obstruc- 
tion. This  is  ascertained  by  the  time  of  the  murmur  and  by  the  direc- 
tion in  which  it  is  transmitted. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     381 

The  Time  of  the  Murmur.  The  time  of  the  murmur  is  determined 
by  the  heart-sounds,  by  the  impulse,  and  by  the  pulse. 

Murmurs  in  the  Mitral  Area.  The  murmur  is  heard  loudest  at  the 
apex. 

1.  It  occurs  with  the  systole.  In  health,  during  this  time,  the 
auriculo -ventricular  valve  is  closed.  If  a  murmur  replaces  the  systolic 
sound  there  is  such  disease  as  to  permit  of  a  backward  flow  of  blood, 

Fig.  76. 


Maximum  intensity  of  murmur  of  mitral  regurgitation  ;  systolic  ;  transmitted  to  the  left. 

or  regurgitation,  into  the  auricle.     It  is  the  murmur  of  mitral  regurgi- 
tation.    It  is  a  systolic  murmur  (see  Fig  76). 

Fig.  77. 


Maximum  intensity  of  murmur  of  mitral  obstruction  ;  presystolic,  localized  or  transmitted  as 

area  shows. 
1.  Normal  impulse.     O.  Area  of  reduplication  of  second  sound. 

2.  It  occurs  before  the  systole,  or  during  the  latter  part  or  middle  of 
the  diastole.     During  this  time,  in  health,  the  blood  is  flowing  through 


382 


SPECIAL  DIAGNOSIS. 


the  left  auricle  to  the  left  ventricle.  There  must  be  such  disease  as 
to  cause  obstruction  to  the  flow  of  blood.  It  is  the  murmur  of  mitral 
obstruction.      It  is  a  presystolic  murmur  (see  Fig.  77). 

Murmurs  in  the  Tricuspid  Area.  The  murmur  is  heard  at  the  xiphoid 
cartilage,  or  fourth  or  fifth  sterno-costal  articulation.  1.  It  is  systolic 
in  time.  For  the  same  reason  as  on  the  left  side,  the  murmur  is  due 
to  disease  which  permits  of  regurgitation,  tricuspid  regurgitation  (see 

Fis-78)- 

2.  In  rare  instances  a  murmur  may  be  heard  in  the  tricuspid  area 
in  the  diastole,  due  to  tricuspid  obstruction.  It  is  so  rare,  however,, 
that  it  does  not  need  further  consideration. 

Murmurs  in  the  Aortic  Area.  The  murmur  is  heard  loudest  at  the 
second  costal  cartilage  on  the  right.  1.  It  is  heard  with  the  systole* 
During  this  time  the  blood  is  flowing  from  the  ventricle  into  the  aorta. 
There  is  such  disease  as  to  cause  obstruction  at  the  orifice.  It  is  the 
murmur  of  aortic  obstruction.     It  is  a  systolic  murmur  (see  Fig.  79). 


Fig.  78. 


Maximum  intensity  of  murmur  of  tricuspid  regurgitation  :  systolic. 

2.  It  is  heard  in  the  diastole,  with  or  replacing  the  second  sound. 
During  this  time,  in  health,  the  blood  falls  back  on  the  aortic  leaflets. 
If  they  are  diseased  to  such  a  degree  as  to  permit  a  portion  of  the  blood 
to  flow  backward  into  the  ventricle,  a  murmur  is  created.  Regurgita- 
tion is  produced  and  a  murmur  is  heard — the  murmur  of  aortic  regurgi- 
tation.    It  is  a  diastolic  murmur  (see  Fig.  80). 

Murmurs  in  the  Pulmonary  Area.  1.  It  occurs  with  the  systole. 
The  murmur  is  heard  loudest  at  the  second  interspace  on  the  left.  The 
pulmonary  orifice  is  affected  in  the  same  way  as  the  aortic  orifice  under 
the  same  circumstances.  The  murmur  is  due  to  pulmonary  obstruction. 
It  is  exceedingly  rare  (see  Fig.  81). 

2.  It  occurs  with  the  diastole,  for  the  same  cause  as  in  aortic  regur- 
gitation. It  is  of  such  extreme  rarity,  it  can  be  practically  excluded. 
It  is  due  to  pidmonary  regurgitation. 

Murmurs  are  divided  as  to  time  into  systolic  and  diastolic  murmurs. 
The  above  shows  that  we  may  have  practically  only  three  systolic  and 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     383 

two  diastolic  murmurs.  The  systolic  murmurs  are  aortic  obstruction 
and  mitral  and  tricuspid  regurgitation.  The  diastolic  murmurs  are 
aortic  regurgitation  and  mitral  obstruction ;  the  former  occurs  in  the 
first  part  of  the  diastole  and  accompanies  or  replaces  the  second  sound; 
the  latter  in  the  diastole,  either  in  the  last  part  and  hence  before  the 
systole,  or  in  the  middle  of  the  diastole. 

Fig.  79. 


Position  of  maximum  intensity  and  directions  of  transmission  of  murmur  of  aortic  obstruction. 

Direction  in  which  the  Murmur  is  Transmitted.     This  de- 
pends upon  the  situation  of  the  murmur  and  the  time  at  which  it  is 

Fig.  80. 


Positions  of  maximum  intensity  and  directions  of  transmission  of  murmur  of  aortic  regurgitation. 

produced.     Some  murmurs  are  not  transmitted.     The  transmission  is 
usually  in  the  direction  of  the  currents  which  produce  them. 

Murmurs  in  the  Mitral  Area.     A  murmur  which  is  produced  at  the 
apex  with  the  systole,  caused  by  regurgitation  at  the  mitral  orifice,  is 


384 


SPECIAL  DIAGNOSIS. 


transmitted  into  the  axilla,  and  may  be  heard  at  the  angle  of  the  scapula. 
The  murmur  which  is  produced  in  the  same  area  before  the  systole  is 
not  transmitted  over  the  body  of  the  heart.  It  is  heard  at  the  apex, 
or  a  little  inside  of  the  apex,  or  may  rarely  have  its  point  of  maximum 
intensity  in  the  third  interspace  (see  Figs.  76  and  77). 

Murmurs  in  the  Tricuspid  Area.  The  murmur  of  tricuspid  regur- 
gitation is  not  transmitted.  It  is  heard  over  a  relatively  large  area, 
depending  upon  the  intensity  of  the  sounds. 

Murmurs  in  the  Aortic,  Area.  The  murmur,  systolic  in  time,  heard 
at  the  second  costal  cartilage  on  the  right,  due  to  aortic  obstruction,  is 
transmitted  in  the  direction  of  the  blood-current.  The  sound  is  con- 
ducted by  the  vessels  and  by  the  fluid  ;  it  is  therefore  heard  along  the 
course  of  the  aorta  and  in  the  carotid  arteries.  The  murmur  of  aortic 
regurgitation,  heard  in  the  same  area,  is  transmitted  downward  along 
the  course  of  the  sternum.  It  may  be  transmitted  to  the  apex,  or  may 
be  heard  along  the  sternum  only.  The  left  ventricle  conducts  this 
murmur  (see  Figs.  79  and  80). 

Character  of  the  Murmurs.  Murmurs  are  studied  in  accord- 
ance with  the  above,  as  to  their  situation,  their  time,  and  the  direction 


Fig.  81. 


Maximum  intensity  of  pulmonary  systolic  murmur. 
O.  Area  of  murmur  of  anaemia. 


in  which  they  are  transmitted.  In  addition,  we  study  the  character  o* 
the  murmur  and  the  degree  of  loudness.  By  the  character  of  the  mur- 
murs we  are  aided  (1)  in  distinguishing  them  from  heart-sounds  ;  (2)  in 
estimating  the  nature  of  the  lesion  that  produces  the  murmur  ;  (3)  in 
judging,  in  the  case  of  murmur  of  mitral  obstruction,  of  the  presence 
or  absence  of  that  disease. 

Distinction  from  Normal  Sounds.  Normal  sounds  are  sounds  of  ten- 
sion; murmurs  are  sounds  of  rhythmical  vibration.  The  normal  sounds 
of  the  heart  have  been  described  by  the  syllable  "  ubb"  "  dupp"  uod" 
and  abnormal  sounds  of  endocardial  origin  by  "  uf"  "  uv,"  "us,"  "ush," 
or  by  full  vowel  sounds  as  "  oo,"  "  u"  "  ah,"  and  "  aw"  by  musical 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     385 

tones,  or  by  interrupted  tones,  or  hearing  general  sounds,  as  "  urr  "  or 
i(  orr."  The  nature  of  the  lesion.  The  murmurs  may  be  rough  or 
rasping,  musical  or  whistling  in  character.  They  may  be  high  in  pitch 
or  low  in  pitch.  Murmurs  that  are  rough  and  high  in  pitch  are  usually 
due  to  such  disease  of  the  valves  as  causes  thickening  or  stiffening 
of  the  leaflets,  or  to  the  projection  of  an  atheromatous  plate  into  the 
lumen  of  the  orifice.  Such  conditions  occur  in  chronic  endarteritis 
and  chronic  endocarditis  or  valvulitis.  On  the  other  hand,  murmurs 
that  are  soft  and  low  in  pitch  are  usually  due  to  a  physical  condition 
which  causes  swelling  of  the  valve  or  occlusion  by  soft  exudations  ; 
they  are  heard  in  endocarditis  of  rheumatic  origin,  or  the  malignant 
form  of  endocarditis.  The  only  murmur  which  has  special  character- 
istics is  the  murmur  of  mitral  obstruction.  It  is  a  prolonged  murmur 
of  a  churning  or  grinding  character,  sometimes  rippling,  and  as  if  fluid 
were  being  forced  through  a  narrow  channel.  .  It  is  usually  presystolic, 
but  may  occur  in  the  middle  of  the  diastole.  Loudness.  The  loud- 
ness of  the  murmur  is  not  of  special  significance,  although,  in  general, 
it  may  be  said  that  it  indicates  good  compensation,  and  that  the  force 
which  produces  the  blood  is  sufficient  to  meet  the  demands  of  the 
circulation.  Murmurs  are  louder  in  the  recumbent  than  in  the  erect 
posture  in  some  instances,  especially  mitral  and  tricuspid  murmurs. 
Murmurs  are  more  distinct  often  after  exertion.  Loud  murmurs  may 
become  weak,  and  this  change  in  character  of  the  sound  is  of  serious  omen. 
They  may  disappear  in  the  course  of  fevers  and  in  the  dying  state. 

Disappearance  of  Murmur.  The  student  will  often  find  that  after  a 
patient  has  been  under  treatment  for  a  short  time  the  murmurs  dis- 
appear. This  is  probably  due  to  the  fact  that  there  is  complete  com- 
pensation. In  other  cases  it  may  be  necessary  to  bring  out  a  faint 
murmur  or  increase  its  intensity  by  having  the  patient  move  about;  this 
renders  it  more  distinct  by  inducing  more  rapid  action  of  the  heart. 

Murmurs  due  to  Incompetency.  The  valves  are  sometimes 
unable  to  close  properly.  The  cavity  of  the  ventricles  may  increase 
in  size,  so  that  the  valves  do  not  coaptate  properly  to  close  the  widened 
orifice.  The  tricuspid  and  mitral  valve  leaflets  often  become  thus  incom- 
petent. Mitral  and  tricuspid  regurgitation  ensue.  The  murmurs  are 
soft  and  low  in  pitch  and  not  widely  transmitted;  the  heart  is  dilated. 

The  Murmurs  of  An.emia.  Having  ascertained  a  murmur  and 
the  orifice  at  which  it  is  created,  we  have  to  distinguish  whether  the 
murmur  is  due  to  disease  of  the  valves  or  whether  it  is  due  to  anaemia. 
The  murmurs  of  anseniia  have  some  characteristics  which  aid  in  distin- 
guishing them  from  the  true  organic  murmurs.  The  most  important 
of  these  are:  (1)  the  situation  of  the  murmur;  (2)  its  character  ;  (3) 
the  direction  in  which  it  is  transmitted;  (4)  the  time;  (5)  the  associate 
signs;  (6)  the  secondary  heart-muscle  changes.  1.  The  murmurs  of 
anaemia  may  be  heard  at  any  orifice,  but  are  usually  heard  at  the  sec- 
ond costal  cartilage,  or  the  third  interspace,  on  the  left  side.  They 
arc  generated  at  tin;  pulmonary  orifice,  or  in  the  cone  of  the  righl 
ventricle.  The  murmur  at  the  pulmonary  orifice  may  be  heard  as 
high  as  the  second  interspace,  but  otherwise  i-  not  transmitted.  Mur- 
murs of  anaemia  are  also  heard  at  the  apex,  at  the  aortic  cartilage, 

25 


386  SPECIAL  DIAGNOSIS. 

and  over  the  tricuspid  area.  They  are  comparatively  infrequent  in 
these  situations,  but  partake  of  the  same  nature  as  the  murmur  heard 
at  the  pulmonary  orifice.  2.  They  are  soft  in  character,  and  low  in 
pitch.  They  are  louder  in  the  recumbent  than  in  the  upright  posi- 
tion. Their  loudness  is  increased  by  violent  cardiac  action.  They  are 
loudest  just  at  the  end  of  expiration  or  beginning  of  inspiration. 
3.  They  are  not  transmitted  away  from  the  heart.  4.  They  are 
systolic  in  time.  5.  They  are  associated  with  murmurs  in  other 
parts  of  the  vascular  system,  as  the  murmur  in  the  jugular  veins.  Its 
characteristics  and  mode  of  recognition  will  be  described  elsewhere. 
6.  Mural  changes,  as  general  dilatation,  fatty  degeneration,  or  hyper- 
trophy may  be  present  ;  but  single  chambers  do  not  undergo  change. 
The  murmur  of  anaemia  may  usually  be  considered  to  be  temporary. 

Fig.  82. 


Maximum  intensity  of  murmurs  of  ansemia,  systolic.    (Sansom.) 

1.  Pulmonary  artery,  59  per  cent.    2.  Apex,  7  per  cent.    3.  Right  v.  and  conus,  11  per  cent. 

4.  Aortic  area,  11  per  cent.    1  and  2.  Pulmonary  and  apex  co-existing,  9  per  cent. 

Functional  Murmurs  not  Ancemic.  Drummond  divides  functional 
murmurs  into  three  classes  :  cardio-h acinic  or  anaemic  ;  cardio-muscular 
or  neuro-typtic,  and  cardio-respiratory.  The  first  has  been  consid- 
ered above.  The  cardio-muscular  murmur  attends  excited  action  of 
the  heart.  It  is  heard  loudest  at  the  fourth  left  interspace  close  to 
the  sternum  ;  loudest  in  the  upright  posture ;  loudest  at  the  end  of 
expiration.  It  disappears  at  the  end  of  inspiration,  or  when  the 
patient  lies  on  the  side.  Of  course,  it  is  increased  by  exertion  and 
excitement.  It  is  rough  or  whizzing  in  character.  The  cardio-res- 
piratory murmur  is  fairly  common.  It  is  most  marked  in  inspiration, 
but  may  be  heard  in  both  acts.  It  is  systolic  in  time,  and  is  heard 
loudest  at  the  apex,  but  I  have  often  heard  it  along  the  left  border  of 
the  heart,  as  high  as  the  second  rib  and  in  the  axilla,  and  at  the  angle 
of  the  scapula.  It  is  short  and  whiffing,  and  the  sound  gives  one 
the  impression  the  heart  is  striking  the  lung. 

The  Significance  of  Murmurs.  Murmurs  heard  at  the  various 
orifices  indicate  disease  causing  obstruction  or  incompetency  of   the 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     387 

valve,  disease  of  the  blood,  or  disease  of  the  vessels  in  intimate  rela- 
tion with  the  heart.  The  systolic  murmur  at  the  second  costal  cartilage 
on  the  right  may  be  heard  when  there  is  disease  at  the  aortic  orifice, 
causing  obstruction;  in  atheroma  of  the  aorta;  in  cases  of  aneurism 
just  above  the  valves;  in  anaemia,  and  chlorosis,  and  in  some  affec- 
tions with  vasomotor  neuroses,  as  Graves'  disease.  Before  concluding 
that  the  murmur  is  due  to  disease  of  the  valves  we  must  be  able 
to  exclude  the  other  conditions.  Atheroma  of  the  aorta  is  most 
difficult  to  distinguish  from  obstruction,  because  the  character  of  the 
murmur  is  the  same  and  the  associated  conditions  are  similar.  In  both 
there  may  be  a  previous  history  of  gout,  rheumatism,  syphilis,  or  alco- 
holism. The  latter  is  associated  with  atheroma  in  other  arteries  of 
the  body,  and  with  degenerative  changes  that  accompany  atheroma. 
In  young  subjects,  in  whom  there  has  been  a  direct  history  of  rheu- 
matism, or  when  the  process  has  followed  septicaemia,  the  probabilities 
are,  in  nearly  all  the  cases,  that  the  murmur  is  due  to  aortic  obstruction. 
To  distinguish  the  murmur  of  anaemia,  chlorosis,  or  Graves'  disease  is 
often  difficult.  The  associate  symptoms  in  each  case  are  different, 
however,  and  then  the  changes  in  the  blood  are  such  as  to  indicate  the 
nature  of  the  murmur. 

Secondary  Effect  of  Valve-lesions  on  the  Heart  and 
Polse.  While  we  are  enabled  by  the  time  of  the  murmur,  the  posi- 
tion, and  the  direction  of  transmission  to  affirm  the  nature  of  the  dis- 
ease at  the  respective  valve-orifices,  other  physical  signs  of  diagnostic 
significance  aid  us  in  determining  more  precisely  the  lesion  and  its  seat. 
They  are  derived  from  the  heart  and  the  pulse.  They  depend  upon  the 
secondary  effect  of  the  lesion  upon  the  heart  and  upon  the  circulation. 
In  aortic  obstruction,  on  account  of  obstruction  to  the  flow  of  blood,  the 
left  ventricle  hypertrophies;  moreover,  the  blood-stream  is  lessened  in 
volume,  and  hence  the  pulse  is  small  and  it  is  of  high  tension.  The 
physical  signs  of  hypertrophy  and  small  pulse  are  corroborative  evi- 
dence of  this  lesion  at  the  left  orifice.  In  aortic  regurgitation  the  blood 
flows  back  into  the  ventricles.  On  this  account,  therefore,  some  dila- 
tation takes  place,  a  dilatation  which,  if  compensation  is  perfect,  is 
overcome  by  hypertrophy.  The  signs,  however,  of  enlarged  left  heart 
are  present,  as  shown  by  inspection,  palpation,  and  percussion.  But 
the  pulse  of  aortic  regurgitation  is  of  the  greatest  diagnostic  signifi- 
cance. With  the  finger  on  the  radial,  the  impression  is  at  once  re- 
ceived of  recedence  of  the  pulse-wave  as  soon  as  it  strikes  the  finger. 
This  i-  more  marked  if  the  hand  is  elevated.  It  is  the  water-hammer, 
or  Corrigan's,  pulse.  In  mitral  regurgitation  the  left  auricle  does  not 
change,  but  the  stress  is  thrown  upon  the  right  side  of  the  heart,  and 
we  have  the  signs  of  right-sided  hypertrophy  and  dilatation;  but  more 
marked  than  this  is  the  evidence  of  high  tension  of  the  pulmonary 
artery,  shown  by  accentuation  of  the  second  sound  (see  p.  .!7'>).  In 
mitral  regurgitation,  the  blood  flows  back  into  the  auricle  and  ingoir/es 
the  venous  system.  The  arterial  system  is  devoid  of  blood,  and  hence 
the  arteries  are  empty.  The  pulse  is  small  and  feeble  ;  the  depleted 
coronary  arteries  do  not  nourish  the  ventricles.  Dilatation  or  failure 
in  nutrition  soon  ensues,  and  the  heart  is  weakened,      in  addition  to  a 


388  SPECIAL  DIAGNOSIS. 

small  and  feeble  pulse,  on  account  of  inefficient  and  hurried  contrac- 
tions of  the  ventricle,  it  is  irregular  and  intermittent. 

In  mitral  obstruction,  in  addition  to  the  characteristic  murmur,  the 
thrill  is  of  great  significance.  Moreover,  the  left  auricle  hypertrophies, 
and  shortly  afterward  the  right  heart.  It  is  accompanied  by  an  accen- 
tuated pulmonary  second  sound,  and  frequently  by  doubling  of  that 
sound.     The  pulse  is  small  and  feeble. 

Multiple  Cardiac  Murmurs.  More  than  one  murmur  may  be  heard 
over  the  heart.  The  number  depends  upon  the  number  of  valves  that 
are  the  seat  of  disease,  and  the  lesions  at  the  orifices.  We  may  have 
valvulitis  of  the  aortic  and  mitral  valves,  and,  in  addition,  of  the  tri- 
cuspid. More  commonly  one  valve  is  diseased,  and  murmurs  are 
heard  at  that  orifice  ;  while  another  valve  is  incompetent  on  account 
of  dilatation,  and  in  consequence  a  murmur  is  generated  at  its  orifice. 
It  is  common  to  see  aortic  obstruction  from  valvulitis  and  mitral  re- 
gurgitation from  incompetency  ;  mitral  obstruction  or  regurgitation 
from  valvulitis,  and  tricuspid  regurgitation  from  incompetency.  I  have 
seen  double  aortic  disease  (combined  obstruction  and  regurgitation), 
double  mitral  disease,  and  tricuspid  regurgitation.  The  diagnosis  of 
the  various  murmurs  will  be  discussed  in  the  chapter  on  Valvulitis. 

Examination  of  the  Arteries  and  Veins.  The  state  of  the"  cir- 
culation in  the  arteries  and  veins  is  greatly  influenced  by  the  condition 
of  the  heart.  Their  examination  yields  data  of  diagnostic  value  in 
the  discrimination  of  heart  disease.  It  is  appropriate  to  describe  the 
method  of  examination  before  proceeding  with  the  diseases  of  the 
heart. 

The  Arteries.  Inspection.  By  inspection  we  may  be  able  to  de- 
termine pulsation  or  any  undue  swelling  or  other  change  in  the  course 
of  the  vessels.  With  the  exception  of  pulsation  in  the  carotids,  which 
may  temporarily  increase  under  excitement,  pulsation  of  the  vessels  is 
not  usually  seen  in  health.  In  old  people  we  can  see  the  pulsation  of 
the  aorta  (rarely)  at  the  episternal  notch,  the  temporals,  the  innominate, 
the  carotids,  the  subclavian^,  the  brachial  and  radial  arteries,  the 
abdominal  aorta  in  thin  subjects,  the  femoral  arteries  and  the  posterior 
tibials. 

The  Artertes  rsr  the  Neck.  Temporary  pulsation  of  the  carotid 
arteries  from  excitement  has  been  mentioned.  It  is  commonly  seen 
in  anaemia,  and  quite  marked  in  exophthalmic  goitre.  It  is  striking 
in  aortic  regurgitation.  It  often  attends  the  vascular  changes  of  old 
age.  It  may  be  due  to  atheroma  or  aneurism.  It  is  always  suggestive 
of  aortic  valvular  disease.  The  innominate  artery  as  well  as  the 
carotids,  often  pulsates  visibly  in  the  neck,  and  may  be  so  large  as  to 
simulate  aneurism.  The  subclavians  may  pulsate  for  the  same  reasons; 
they  may  also  be  seen  to  pulsate  if  the  lungs  are  consolidated  or 
shrunken  by  disease.  If  the  patient  is  young,  the  throbbing  is  more 
likely  to  be  of  neurosal  or  hsemic  origiu. 

The  Aorta.  In  pulsation  of  the  thoracic  aorta  the  impulse  is  seen 
in  the  course  of  the  vessel,    usually  from  aneurism.      The  pulsation 


DISEASES  OF  HEART.  BLOODVESSELS,  AND  MEDIASTINUM.     389 

is  not  always  due  to  disease.  The  aorta  may  be  pushed  against  the 
chest-wall,  or  the  lung  structure  which  overlaps  it  normally  may  be 
withdrawn  by  shrinkage. 

The  Abdominal  Aorta.  Pulsation  of  the  abdominal  aorta  is  often 
the  cause  of  serious  distress.  The  violent  throbbing  keeps  the  patient 
awake  at  night,  and  makes  him  more  and  more  nervous  and  irritable. 
The  pulsation  is  usually  seen  in  the  epigastrium.  It  is  more  frequent 
when  the  vessel  is  not  diseased,  in  neurasthenic  subjects.  It  occurs 
reflexly  in  patients  with  dyspepsia  or  organic  disease  in  the  upper 
abdominal  tract.  The  shock  of  the  pulsation  is  transmitted  to  the  hand 
with  considerable  violence.-    The  impulse  is  diffused,  but  not  expansile. 

Epigastric  pulsation  also  may  be  due  to  the  transmission  of  the  impulse 
of  the  aorta  by  enlargement  of  the  pancreas,  or  tumors  of  the  stomach 
or  the  omentum.  The  transmitted  pulsation  is  distinct.  The  impulse 
is  a  transmitted  one  when  the  tumor  can  be  denned  and  when  a  sensa- 
tion of  lifting  is  transmitted  to  the  hand.  The  physical  signs  of  aneu- 
rism are  absent.  If  the  patient  lies  on  the  abdomen,  or  in  the  knee- 
chest  position,  the  tumor  falls  away  from  the  aorta,  and  the  impulse  is 
not  readily  transmitted.  Epigastric  pulsation  is  also  caused  by  aneu- 
rism of  the  abdominal  aorta.  The  pulsation  is  dis tensile  or  expansile, 
and  the  aneurismal  sac  can  be  defined  at  times.  The  other  physical  signs 
of  aneurism  are  usually  present,  namely,  thrill,  dulness  over  the  tumor, 
a  murmur  on  auscultation.  In  these  conditions,  however,  we  cannot 
always  rely  on  the  physical  signs  alone;  the  history  of  the  subjective 
symptoms  of  disease  of  other  structures  must  be  carefully  inquired 
into.  Aneurism  rarely  occurs  without  some  evidence  of  arterial  scle- 
rosis or  some  physical  effect  upon  the  circulation.  Accentuation  of 
aortic  second  sound,  variations  in  the  femoral  pulse,  high  arterial  ten- 
sion, and  the  evidences  of  sclerosis  favor  aneurism.  While  epigastric 
pulsation  due  to  pulsation  of  the  aorta  usually  occurs  in  neurotic  sub- 
jects, and  hence  in  the  earlier  periods  of  life,  yet  such  pulsation  is  fre- 
quently seen  in  the  aged,  and,  with  fibrous  thickening  about  the  pylorus, 
or  contraction  of  the  omentum,  may  easily  be  confounded  with  malig- 
nant disease,  which  is  more  common  during  this  period  of  life.  Can- 
cer of  the  stomach  has  been  diagnosticated  under  these  circumstances 
when  the  pulsation  was  simply  reflex  from  chronic  gastritis.  Some 
time  ago  a  private  patient  in  the  Presbyterian  Hospital  had  extreme 
pulsation  of  the  abdominal  aorta,  with  great  local  discomfort  on  account 
of  the  throbbing.  She  was  sixty-five  years  of  age,  and  had  within  the 
past  two  years  nursed  her  son  through  tuberculosis.  She  failed  in 
health,  and  came  to  the  hospital  emaciated,  with  pronounced  chronic 
gastritis  and  diarrhoea.  On  examination,  above  the  umbilicus  a  distinct 
tumor  was  felt,  which  she  had  been  told  was  due  to  carcinoma.  It 
was  hard  and  painless;  the  physical  signs  of  aneurism  were  not  presenl ; 
the  pulsation  was  extreme.  A  second  tumor,  not  so  large,  was  tilt  in 
the  right  hypochondriac  region.  Both  tumors  were  dull  upon  percussion 
and  surrounded  by  tympanitic  areas.  They  were  also  movable.  N\  bile 
it  was  impossible  to  be  sure  of  the  nature  of  the  tumors,  it  seemed  to 
me  they  were  tuberculous,  or  simply  fibrous,  and  would  not  influence 
the  patient's  immediate  welfare.      Under  treatment,  the  pulsation  (lis- 


390  SPECIAL  DIAGNOSIS. 

appeared  ;  the  gastrointestinal  symptoms  were  relieved  entirely;  the 
patient  rapidly  gained  in  weight  and  strength;  the  tumors  continued, 
but  they  are  not  so  distinctly  outlined  because  the  previously  scaphoid 
abdomen  has  become  distended  (two  years  under  observation).  The 
questions  arose  for  decision :  Was  the  epigastric  pulsation  due  to  a 
throbbing  aorta  or  transmitted  by  an  obscurely  defined  mass  in  that 
region  ?  No  doubt  it  was  the  vessel  alone  that  caused  the  impulse. 
The  diagnosis  must  be  made  by  carefully  weighing  all  concomitant  cir- 
cumstances and  phenomena  that  surround  cancer  (see  Symptomatology 
of  Morbid  Processes).  Fceeal  accumulations  in  the  colon  may  be  made 
to  heave  by  the  beat  of  the  aorta  and  cause  exaggerated  epigastric 
impulse.  The  bowels  must  be  emptied  before  definite  conclusions  are 
arrived  at. 

An  epigastric  impulse  due  to  one  of  the  above-mentioned  causes 
must  not  be  confounded  with  the  impulse  of  hypertrophy  of  the 
right  ventricle,  or  to  the  shock  of  the  hypertrophied  heart  trans- 
mitted to  the  left  lobe  of  the  liver.  In  hypertrophy  of  the  right  ven- 
tricle or  dislocation  of  the  heart  from  disease  within  the  chest,  the 
impulse  may  be  seen  to  the  right  or  left  of  the  xiphoid  cartilage.  The 
symptoms  and  signs  of  right-ventricle  hypertrophy  explain  the  pulsa- 
tion. 

The  Smaller  Arteries.  By  inspection  of  the  arteries  beyond  the  ab- 
dominal aorta  we  can  often  recognize  more  distinctly  the  condition 
known  as  arterio-sclerosis.  Similar  examination  of  the  brachial  and 
radial  arteries  reveals  the  same  condition,  the  changes  of  which  will 
be  spoken  of  when  that  disease  is  considered  (see  Arterio-sclerosis). 
Bnt  pulsation  of  the  above-mentioned  peripheral  arteries  may  be  due 
to  other  causes.  In  hypertrophy  of  the  left  ventricle  arterial  pulsation 
is  prominent,  "although  more  marked  in  the  vessels  near  the  heart,  as 
the  carotids.  In  regurgitation  at  the  aortic  orifice,  pulsation  is  also 
frequently  seen. 

Elongation  of  this  artery,  so  that  instead  of  a  straight  tube,  it  be- 
comes a  sinuous  canal,  turning  and  twisting  at  short  intervals,  is  seen  in 
endarteritis. 

Capillary  Pulse.  The  capillary  pulse  is  seen  under  the  finger- 
nails or  in  the  skin  after  hyperemia  is  induced  by  firmly  stroking  the 
skin  with  the  nail.  It  may  be  seen  inside  the  lips,  if  a  piece  of  glass 
is  pressed  against  them.  There  is  rhythmical  pulsation  of  the  capilla- 
ries, from  which  the  surface  becomes  alternately  white  and  red.  It 
is  a  sign  of  aortic  insufficiency. 

Palpation.  (See  the  sections  on  Aneurism,  Arterio-sclerosis,  and 
the  Pulse.)  The  results  of  inspection  are  confirmed.  In  addition, 
the  artery  is  examined  to  determine  its  tension,  the  character  of  the 
coats,  and  the  presence  of  thrills.  Pulsation  of  Organs.  It  is  said 
that  in  aortic  regurgitation  an  arterial  liver-pulse,  similar  to  the  venous 
liver-pulse,  can  be  felt  when  the  hands  are  placed  over  that  organ. 
Similar  pulsation  may  be  felt  in  the  spleen. 

In  examining  the  arteries  it  is  important,  as  will  be  detailed  in  the 
chapter  devoted  to  the  pulse,  to  compare  the  arteries  of  the  two  sides. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     391 

Often  the  pulse-wave  is  found  to  be  unequal  in  force,  in  volume,  and  in 
time.  This  is  almost  always  due  to  obstruction  to  the  passage  of  the 
blood.  When  not  due  to  endarteritis  or  to  aneurism,  it  is  due  to  the 
pressure  of  a  tumor  on  the  vessel  somewhere  in  its  course.  A  thrombus 
or  embolus  in  the  artery  may  likewise  cause  the  condition.  A  difference 
in  the  radial  and  the  femoral  pulse  points  to  obstruction  in  the  thoracic 
or  abdominal  aorta.   Anatomical  variations  must  be  remembered. 

The  Pulse. 

The  pulse  is  an  index  to  the  force,  frequency,  and  rhythm  of  the 
heart's  action  and  of  the  pressure,  or  tension,  which  is  maintained  in 
the  arteries. 

General  Observations.  The  frequency  of  the  pulse  before  birth 
is  from  120  to  140  beats  in  the  minute.  From  this  time  it  is  diminished 
in  frequency  up  to  adult  life,  72  being  then  accepted  as  an  average; 
the  number  of  beats,  however,  is  often  under  72,  and  sometimes  over 
that.  In  old  age  the  pulse-rate  is  again  increased.  Sex  has  some  influ- 
ence.    The  rate  is  slightly  higher  in  females  than  in  males  of  the  same 

aSe-  .  .  ... 

The  frequency  of  the  pulse  is  subject  to  diurnal  variations,  at  times 

correspond  ng  with  the  diurnal  rise  and  fall  of  temperature.     The  rate 

will,  therefore,  be  highest  in  the  afternoon  and  evening  and  lowest  in 

the  early  morning  hours. 

The  position  of  the  body  has  also  a  modifying  influence.  The  pulse 
is  more  frequent  when  a  person  is  standing  than  when  he  is  sitting,  and 
more  frequent  when  he  is  sitting  than  when  he  is  lying  down.  Walk- 
ing, running,  bodily  and  mental  exertion,  fear,  and  excitement  all  tend 
to  accelerate  the  pulse. 

During  and  for  one  or  two  hours  after  a  meal  the  pulse-rate  is  higher, 
especially  if  an  alcoholic  or  other  stimulant,  such  as  coffee,  has  been 
taken. 

How  to  Take  the  Pulse.  To  make  a  correct  count  of  the  fre- 
quency of  the  pulse,  the  conditions  just  mentioned,  as  normally  modi- 
fying its  rate,  should  be  borne  in  mind.  If  the  object  of  the  count  is 
to  determine  the  rate  which  is  normal  for  a  particular  individual,  sev- 
eral counts  will  be  necessary  at  different  times  and  under  different  con- 
ditions, such  as  sitting  and  standing.  The  best  time  for  the  physician 
to  take  the  pulse  will  have  to  be  determined  by  his  own  judgment  in 
each  case.  If  the  patient  comes  to  his  office  and  is  excited  by  the 
prospect  of  an  examination,  it  will  be  well  to  wait  until  he  becomes 
calm.  On  the  other  hand,  if  he  is  calm  at  first,  a  count  at  that  time 
is  to  be  preferred  to  one  made  after  the  patient  has  been  disturbed  by  a 
physical  examination.  In  the  same  manner,  on  visiting  a  patient  at  his 
hous?,  the1  judgment  of  the  physician  must  decide  whether  to  coiini  the 
pulse  immediately  on  his  arrival  or  to  postpone  it  until,  by  general  con- 
versation, all  apprehension  and  alarm  on  the  part  of  the  patient  have  been 
allayed.  In  general  it  may  be  said  that  if  the  physician  findsupon  lii- 
arrival  that  the  pulse  is  more  frequent  than  the  condition  of  the  patieni 
would  lead  him  to  expect,  he  should  wait  awhile,  endeavor  to  fiud  out 


392  SPECIAL  DIAGNOSIS. 

whether  anything  has  served  temporarily  to  disturb  the  circulation,  and 
then  make  the  count  when  the  conditions  are  most  favorable.  Some 
patients  are  so  nervous  that  the  mere  act  of  placing  the  finger  upon  the 
wrist  sends  the  pulse-rate  up  ten  or  twenty  beats  in  the  minute.  In 
such  cases  an  effort  should  be  made  to  obtain  a  count  without  the  pa- 
tient' s  knowledge  by  observing  the  pulsations  of  the  temporal  or  carotid. 
In  other  cases  it  may  be  well  to  entrust  the  counting  of  the  pulse  to 
the  nurse  or  to  a  member  of  the  family.  In  infants  and  young  chil- 
dren, count  while  they  are  asleep.  In  febrile  conditions  the  connt  is 
more  likely  to  be  too  high  than  too  low. 

In  hospital  practice,  or  when  a  nurse  is  in  constant  attendance,  the 
pulse  and  respiration  should  be  taken  at  the  same  time  as  the  tempera- 
ture. Bat  the  nurse  must  be  warned  against  taking  them  under  dissimilar 
conditions  upon  successive  days.  For  example,  the  pulse  should  not 
be  taken  one  day  while  the  patient  is  lying  down,  quiet  and  comfort- 
able, and  compared  with  the  count  the  next  day  when  the  patient  is 
sitting  up  or  has  just  had  some  hot  liquids,  or  a  spell  of  coughing,  or 
been  subjected  to  some  other  disturbing  influence. 

The  preferable  position  is  the  recumbent  one  in  the  case  of  patients 
in  bed,  and  the  sitting  position  in  those  not  confined  to  bed.  Care 
should  be  exercised  in  all  cases  to  see  that  the  patient' s  position  is  com- 
fortable and  that  nothing  obstructs  the  artery  or  interferes  with  the 
unimpaired  flow  of  the  blood. 

The  wrist  is  the  place  usually  selected  at  which  to  feel  the  pulse. 
At  this  point  the  radial  artery  passes  over  the  radius,  and  can  readily 
be  compressed  and  its  character  made  out.  An  old-fashioned  rule  pre- 
scribes that  three  fingers  should  be  applied  to  the  artery,  the  index- 
finger  of  the  physician  being  nearest  the  heart.  In  particular  cases  it 
may  be  advisable  to  count  the  pulse  at  the  temporal  or  carotid  artery. 
The  fingers  should  be  applied  so  that  the  beats  can  be  most  distinctly 
felt.  The  beats  are  counted  for  fifteen  seconds  by  the  second  hand  of 
a  watch  when  only  an  approximately  correct  count  is  desired,  or  wheu 
time  is  a  factor,  and  then  multiplied  by  four.  It  is  better  to  count  the 
pulse  for  half  a  minute,  and  still  better  for  a  fall  minute. 

The  arteries  of  the  two  sides  must  be  compared.  Difference  in  the 
force,  volume,  and  time  may  be  due  to  the  anomalous  distribut'on  of 
arteries.  In  disease,  it  may  occur  in  aneurism  and  atheroma,  in  pres- 
sure on  the  trunk  from  external  disease,  and  in  embolism  and  throm- 
bosis. 

Condition  of  the  Walls  of  the  Artery.  The  condition  of 
th,j  artery  is  often  of  more  importance  than  the  pulse-rate.  A  healthy 
radial  artery,  in  a  person  not  advanced  in  years,  can  be  compressed 
easily  against  the  radius  without  the  finger  being  able  to  differentiate 
the  artery  from  the  other  tissues.  But  as  age  advances,  and  as  the 
result  of  certain  constitutional  diseases — syphilis,  gout,  chronic  endar- 
teritis, alcoholism,  and  others — the  artery  tends  to  become  thicker,  so 
that  in  pronounced  cases  it  cannot  be  obliterated,  but  is  rolled  like 
a  cord  or  pipe-stem  between  the  compressing  fingers  and  the  bone. 
Small  specks  or  plates  of  atheroma,  feeling  like  hard  particles  in  the 
coats  of  the  artery,  may  be  detected.     The  artery  has  a  beaded  feeling. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     393 

Fatty  degeneration  of  the  organs  is  likely  to  occur  when  the  arteries 
are  in  this  condition,  and  apoplexy  is  to  be  feared. 

Tension.  Tension  is  the  word  used  to  express  the  degree  of  blood- 
pressure — that  is,  of  distention  of  the  arteries.  Normally,  the  pulse 
nearly  or  quite  subsides  between  the  beats,  but  little  pressure  being  re- 
quired to  obliterate  it.  High  tension  may  be  said  to  exist  when  the  artery 
remains  continuously  full  between  the  beats  (Broadbent).  It  is  produced 
by  plethora  ;  increased  heart-action  ;  contraction  of  the  arterioles,  as  by 
chill;  and  obstruction  in  the  capillaries.  The  conditions  which  bring 
about  obstruction  in  the  capillaries  in  the  order  in  which  they  are  enum- 
erated by  Broadbent  are  :  1.  Age.  The  liability  to  high  arterial  ten- 
sion increases  with  the  age,  especially  after  middle-life.  2.  Heredity. 
There  is  in  some  families  a  marked  tendency  to  high  tension.  The 
younger  members  show  its  effects  in  headaches  and  bilious  attacks, 
while  the  older  ones  develop  chronic  heart  disease  and  apoplexy. 
3.  Disease  of  the  kidney.  Parenchymatous,  but  especially  interstitial 
nephritis,  is  associated  with  high  arterial  tension;  this,  with  accentua- 
tion of  the  aortic  second  sound,  is  one  of  the  early  and,  therefore,  one 
of  the  most  valuable  indications  of  chronic  Bright' s  disease.  4.  Gout. 
Gout  and  lithsemia  are  almost  always  accompanied  by  high  arterial 
tension.  5.  Diabetes  in  old  persons  associated  with  gout.  6.  Lead- 
poisoning.  7.  Pregnancy.  8.  Anaemia.  9.  Emphysema  and  chronic 
bronchitis.      10.   Mitral  stenosis. 

As  regards  arterial  tension  in  persons  presenting  signs  of  angina 
pectoris,  Sansom  asserts  that  if  the  tension  is  increased,  even  though 
the  signs  are  not  typical,  the  fear,  present  or  remote,  of  true  angina  is 
justified.  On  the  other  hand,  if  there  is  persistent  low  tension,  espe- 
cially during  the  painful  crisis,  it  is  almost  certain  the  affection  is  a 
false  angina. 

Low  tension  of  the  pulse  is  characterized  by  a  softness  and  a  com- 
pressibility in  excess  of  the  normal.  This,  like  the  high-tension  pulse, 
may  be  a  family  peculiarity.  It  is  met  with  in  conditions  of  great 
depression  and  exhaustion,  and  wherever  there  is  a  marked  cardiac 
weakness.  ,  It  is  most  common  in  fevers,  particularly  in  typhoid,  in 
which  also  an  accompaniment  of  low-tension  pulse,  namely,  dicrotism, 
is  met  with  in  a  marked  degree.  Fat  persons  are  apt  to  have  low- 
tension  pulses,  and  it  may  occur,  in  any  person  temporarily  under  the 
influence  of  external  warmth  and  moisture,  such  as  a  hot  bath,  or  after 
taking  hot  drinks,  or  under  the  influence  of  depressing  emotions,  and 
after  diarrhoea,  or  copious  urination. 

Volume.  The  volume  of  the  pulse  should  be  noted.  It  is  usually 
large  in  conditions  of  pyrexia  and  when  the  tension  is  low.  A  small 
pulse  is  met  with  in  many  conditions  other  than  weakness  of  the  heart- 
muscle.  In  aortic  stenosis  the  pulse  is  small,  and  in  mitral  stenosis  it 
is  small,  of  high  tension,  and  frequently  irregular.  In  general  contrac- 
tion of  the  arterioles,  as  happens  under  the  influence  of  a  chill,  the 
pulse  is  small.  In  Bright' s  disease  it  is  sometimes  very  small,  slow, 
and  hard.  Some  care  will  be  required  to  differentiate  such  a  pulse 
from  a  weak  pulse.  In  acute  peritonitis  the  pulse  is  apt  to  be  small 
and  hard. 


394  SPECIAL  DIAGNOSIS. 

Rhythm.  The  rhythm  of  the  pulse  is  of  diagnostic  importance. 
In  health  one  beat  succeeds  another  at  equal  intervals  of  time,  and  the 
successive  beats  are  of  the  same  force  and  quality.  Here  also,  how- 
ever, as  in  other  conditions,  there  are  variations  within  physiological 
limits.  In  some  persons  the  pulse-rate  is  somewhat  accelerated  during 
respiration  and  becomes  slower  in  the  pauses  which  follow  breathing. 

In  disease,  disturbance  of  the  rhythm  occurs  as  intermission  or  as 
irregularity.  Intermission  signifies  a  dropping  of  a  pulse-beat;  several 
normal  pulse-beats  succeed  each  other,  and  then  the  pulse  is  absent 
during  the  time  occupied  by  one  or  two  beats.  The  intermission  may 
occur  at  regular  or  at  irregular  intervals — that  is  to  say,  every  third, 
fifth,  or  sixth  beat  may  be  wanting,  or  the  intermission  may  be  irreg- 
ular— now  a  second,  the  next  time  a  fifth  or  a  third  beat  being  absent. 
Moreover,  the  intermittent  pulse  may  be  constant,  or  it  may,  and 
more  frequently  is,  only  occasional.  It  is  not  characteristic  of  any  one 
disease  or  condition,  and  it  may  exist  without  the  patient's  knowledge 
and  without  producing  any  perceptible  effect  upon  his  health.  Some- 
times it  is  met  with  in  a  fatty  heart,  and  this  disease  may  be  suspected 
if  the  intermittent  pulse  is  associated  with  a  weak  first  sound  of  the 
heart  without  valvular  lesion,  and  evidences  of  failing  circulation,  such 
as  oedema  of  the  feet.  More  frequently,  however,  the  intermittency 
is  a  symptom  of  nervous  depression,  or  is  caused  by  tea,  coffee,  tobacco, 
or  digitalis.  So  far  as  prognosis  is  concerned,  it  is  much  less  serious 
than  irregularity.  Broadbent  says  he  has  met  with  it  at  the  age  of 
eighty,  when  it  was  known  to  have  existed  for  forty  years. 

Irregularity  is  characterized  by  differences  in  time,  force,  or  volume 
of  successive  beats.  A  full  beat  is  succeeded  by  another,  which  is 
smaller  and  weaker,  or  successive  beats  occur  at  irregular  intervals  of 
time.  Irregulariiy  may  or  may  not  be  associated  with  intermission. 
In  advanced  cases  of  mitral  stenosis  the  pulse  is  both  irregular  and 
intermittent.  The  irregularity  may  be  habitual  or  occasional  ;  the 
former  is  due  most  frequently  to  mitral  lesions,  but  sometimes  occurs 
without  assignable  cause,  and  is  attributed  to  disturbance  of  the  nerve- 
supply  ;  the  latter  is  due  to  digestive  disturbances  and  to  the  effect  of 
nicotine  and  digitalis.  Irregularity  is  not  incompatible  with  health, 
but  is  much  more  likely  to  be  of  serious  import  than  intermission.  It 
occurs  in  diseases  of  the  brain,  in  degeneration  of  the  heart  as  well  as 
in  valvular  lesions,  and  in  grave  cases  of  febrile  diseases,  such  as 
typhus  and  typhoid,  when  the  heart-muscle  is  iuvolved.  Some  cases 
of  Graves'  disease  are  characterized  by  great  irregularity  instead  of 
excessive  rapidity  of  the  pulse.  Irregularity  may  occur  in  rheumatoid 
arthritis  also,  though  increased  frequency  is  the  rule. 

Frequency.  The  frequency  of  the  pulse  is  of  aid  in  diagnosis. 
Increased  frequency.  1.  The  pulse  is  increased  in  frequency  in  all 
the  febrile  diseases,  and  generally  in  the  proportion  of  eight  to  ten 
beats  for  each  degree  of  rise  in  temperatre  above  98.3°.  But  there 
are  important  exceptions.  In  typhoid  fever  the  pulse  is  slower  in 
proportion  to  the  temperature  and  the  gravity  of  the  disease  than  in 
most  of  the  other  acute  febrile  diseases.  It  may  not  beat  above  85 
in  mild  cases,  and  in  severe  cases  frequently  does  not  rise  above  100. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     395 

Consequently  a  pulse  of  120  is  of  much  graver  import  than  it  would 
be  in  other  diseases.  It  may  be  more  frequent  during  convalescence 
than  during  the  febrile  stage.  This  pulse-rate  helps  to  differentiate 
it  from  tuberculosis,  malignant  endocarditis,  and  septicaemia. 

2.  The  pulse  of  scarlet  fever  often  aids  materially  in  diagnosis.  A 
pulse  of  120  to  160  is  the  rule  from  the  development  of  the  sore-throat 
to  the  completion  of  the  eruption.  In  measles,  rubella,  diphtheria, 
and  follicular  tonsillitis  it  is  much  slower  during  the  early  stages. 

3.  In  Graves'  disease  great  frequency  of  the  pulse  is  the  essential 
and  most  constant  symptom  of  the  disease.  The  pulse  may  be  con- 
stantly considerably  over -100,  and  in  attacks  of  palpitation  200  or 
more.  In  these  attacks  there  may  or  may  not  be  precordial  distress  and 
mental  anxiety.  Here  belong  the  cases  described  as  paroxysmal  hurry 
of  the  heart,  etc.,  the  thyroid  and  ophthalmic  symptoms  being  absent. 

4.  Cases  have  been  reported  of  extreme  frequency  of  the  pulse  (160- 
240)  without  palpitation,  dyspnoea,  or  any  signs  of  Graves'  disease. 
Some  of  the  patients  have  been  able  to  perform  much  bodily  and 
mental  labor,  notwithstanding  that  the  rate  mentioned  was  maintained 
persistently  for  weeks.  To  this  class  of  cases  the  name  tachycardia 
has  been  provisionally  applied  until  their  pathology  is  understood. 

5.  In  all  forms  of  valvular  disease,  except  aortic  stenosis  with  failing 
compensation,  the  pulse  may  be  increased  in  frequency.  In  collapse; 
in  weakening  of  the  heart;  and  in  central  or  peripheral  vagus  disease, 
the  pulse  is  increased.  Mitral  stenosis  may  be  latent  until  great  ex- 
citement, overexertion,  and  particularly  running  or  forced  marches 
bring  on  palpitation,  or  simply  abnormal  and  persistent  frequency  of 
the  heart's  action,  with  or  without  dyspnoea. 

6.  Attention  has  been  called,  especially  by  Dr.  J.  Kent  Spender,  to 
acceleration  of  the  pulse  as  an  early  symptom  of  rheumatoid  arthritis. 
The  pulse  increases  gradually  until  it  reaches  a  range  of  110-120,  and 
it  persists  at  that  rate  with  little  diurnal  variation,  even  after  the  arth- 
ritic symptoms  subside. 

7.  In  locomotor  ataxia  permanent  moderate  acceleration  of  the  pulse 
(90-100)  is  a  frequent  symptom. 

8.  In  the  puerperium  increased  frequency  with  irregularity  of  the  pulse 
is  a  surer  indication  of  intrauterine  mischief  than  is  the  temperature. 
So,  too,  in  all  cases  in  which  there  is  a  focus  of  suppuration  so  situated 
that  the  pus  can  be  absorbed  into  the  circulation  but  not  discharged 
externally,  the  pulse  shows  by  its  increased  frequency  that  absorption 
is  going  on. 

Diminished  Frequency.  A  slow  pulse  (bradycardia),  under  60,  like 
a  frequent  pulse,  is  sometimes  habitual,  and  sometimes  a  family  ■char- 
acteristic. Pathologically,  it  is  met  with  in  conditions  which  increase 
the  resistance  in  the  arteries,  such  as  Bright' s  disease,  especially  acute 
glomerulo-nephritis  ;  but  it  is  especially  common  in  jaundice.  The 
bile-acids  have  the  effect  of  retarding  the  action  of  the  heart.  W;  J. 
Pettus  has  reported  a  case  of  bradycardia  associated  with  aneurism 
of  the  right  sinus  of  Valsalva,  involving  the  orifice  of  the  righl  coro- 
nary artery. 

A  slow  pulse  is  met  with  in  certain  forms  of  heart  disease,  as  aortic 


396 


SPECIAL  DIAGNOSIS. 


stenosis,  but  it  is  not  constant  in  any  of  them.  It  occurs  in  fatty  de- 
generation, especially  when  due  to  obstruction,  by  atheroma  or  other- 
wise, of  the  coronary  arteries.  When  it  appears  in  the  late  stages  of 
valvular  affections  or  specific  diseases  with  cerebral  symptoms  it  is 
usually  a  sign  of  danger.  It  is  seen  in  articular  rheumatism  (Atkin- 
son). According  to  Biegel,  it  is  most  common  in  convalescence  from 
acute  disease,  particularly  pneumonia,  typhoid  fever,  erysipelas,  and 
rheumatic  fever.  It  is  also  frequently  encountered  in  diseases  of  the 
digestive  organs  and  of  the  urinary  organs,  particularly  acute  nephritis. 
Moreover,  it  is  generally  slow  in  myxcedema,  and  slow  and  irregular  in 
epilepsy.  It  is  slow  not  uncommonly,  also,  in  melancholia  and  in  the 
early  stage  of  cerebral  meningitis  and  in  tumors  and  cerebral  hemorrhage. 
The  Sphygmograph.  The  sphygmograph,  as  its  name  implies,  is 
an  instrument  for  recording  in  writing  the  volume,  force,  frequency, 
tension,  and  general  characteristics  of  the  pulse.  Many  forms  of  the 
instrument  have  been  devised  since  the  first  one  of  Marey.  The  later 
models  have  the  advantage  of  simplicity  and  ease  of  application.  One 
of  the  most  convenient  is  Dudgeon's.     It  has  its  faults,  particularly 

Fig.  83. 


Dudgeon's  sphygmograph. 


in  exaggerating  the  vibrations  when  the  pulse  is  large  and  the  heart  is 
acting  violently  ;  nevertheless,  with  care,  trustworthy  tracings  can  be 
obtained  in  all  ordinary  cases.  No  matter  what  instrument  is  used,  the 
value  of  the  tracing  depends  very  largely  upon  the  personal  skill  and 
experience  of  the  one  who  takes  the  tracing  ;  hence  the  sphygmograph 
02cupies  a  position  very  different  from  the  thermometer  and  other 
instruments  of  precision.  While  it  is  true  that  a  person  can  learn  to 
detect  nearly  all  the  variations  of  the  pulse  by  palpation  alone,  yet  the 
tracing  has  the  great  advantage  of  permanency,  and  many  persons  are 
led  to  palpate  the  pulse  more  carefully  by  seeing  in  a  sphygmographic 
tracing  a  dicrotism  or  irregularity  which  had  escaped  their  attention. 
The  expansile  pulsation  of  the  artery  is  communicated  by  a  system 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     397 

of  levers  to  a  needle,  which  graphipally  records  the  qualities  of  the 
pulse  upon  smoked  paper. 

Directions  for  Using  Dudgeon's  Sphygmograph. 

1.  Wind  up,  by  the  button,  the  clockwork  contained  in  the  box. 
The  clockwork  carries  the  smoked  paper  under  the  writing-needle. 

2.  See  that  the  patient  is  in  a  comfortable  position,  and  have  him 
hold  toward  you  either  hand  with  wrist  exposed,  fingers  gently  flexed, 
and  muscles  relaxed. 

3.  Apply  the  instrument  by  slipping  the  band  over  the  hand,  the 
free  end  of  the  band  being  passed  through  the  retaining  clamp.  The 
metal  box  is  placed  toward  the  elbow. 

4.  Now  adjust  the  instrument  by  placing  the  bulging  button  which 
connects  with  the  levers  directly  over  the  radial  artery  at  its  most  acces- 
sible point. 

5.  Keep  the  instrument  accurately  in  place  with  the  left  hand,  and 
draw  the  band  through  the  clamp  with  the  right  until  the  writing- 
needle  plays  freely  with  each  pulsation  of  the  radial  artery,  then  fasten 
the  band  by  screwing  up  the  clamp. 

6.  Introduce  the  smoked  paper  between  the  rollers  and  under  the 
writing-needle. 

7.  Vary  the  pressure  by  means  of  the  thumb-screw,  which  connects 
with  an  eccentric,  until  the  best  apparent  amplitude  of  vibration  is 
obtained. 

8.  Instruct  the  patient  not  to  move  the  fingers  or  hand,  and  further 
steady  them  for  him  with  your  own  right  hand. 

9.  Start  the  clockwork  by  pushing  the  bar  at  the  top  of  the  clock- 
work box. 

10.  Allow  the  paper  to  run  through,  and  then  stop  the  clockwork. 
The  clockwork  is  so  regulated  that  five  inches  of  smoked  paper  pass 

through  in  ten  seconds,  so  that  six  times  the  number  of  pulsations 
recorded  on  the  paper  represent  the  pulse-rate  per  minute.  Each 
instrument,  however,  should  be  tested  and  its  time  determined.  The 
clockwork  should  be  wound  up  for  every  tracing. 

Considerable  practice  will  be  required  to  take  a  tracing  rapidly  and 
accurately,  in  spite  of  the  simplicity  of  the  mechanism. 

Several  tracings  should  be  taken  at  different  pressures  and  compared, 
or,  what  is  better,  as  suggested  by  Sansom,  stop  the  clockwork  and 
alter  the  pressure  two  or  three  times,  so  as  to  have  the  effect  of  varying 
pressures  on  one  tracing. 

The  technique  of  sphygmography  needs  a  few  words.  Smoked 
paper  is  generally  used  for  the  tracings.  A  paper  glazed  upon  one 
surface  and  rough  upon  the  other  has  some  advantages.  This  paper 
has  to  be  cut  in  strips  about  seven-eighths  of  an  inch  wide  a  ml  six 
inches  or  more  long.  The  cutting  should  be  done  with  cure  so  thai 
the  edges  are  smooth  and  even,  otherwise  the  paper  sticks  in  the  in- 
strument and  the  tracing  is  spoiled.  The  glazed  surface  is  blackened  by 
holding  it  above  the  flame  of  a  small  piece  of  burning  gum  camphor. 
For  convenience  a  strip  of  tin,  bent  upon  itself  at  each  end,  s<>  as  to 


398  SPECIAL  DIAGNOSIS. 

catch  and  hold  about  an  inch  of  the  ends  of  the  paper,  may  be  used  to 
prevent  the  fingers  from  becoming  blackened  and  to  preserve  the  ends 
of  the  paper  unblackened  for  memoranda.  The  blacking  should  not 
be  too  thick,  otherwise  the  needle  will  not  plough  through  it  easily, 
and  the  white  line  of  the  tracing  will  not  be  distinct.  After  the  tracing 
has  been  made,  the  name  of  the  paitent,  the  diagnosis  of  his  disease, 
the  date  of  the  tracing,  and  the  amount  of  pressure  employed  should 
at  once  be  scratched  with  a  fine-pointed  pen  upon  the  blackened  surface 
beneath  the  tracing,  or  written  in  ink  upon  the  unblackened  end  of  the 
paper.  The  tracing  is  then  ready  for  preservation.  This  is  done  by 
dipping  it  in  a  solution  of  shellac  or  in  tincture  of  benzoin  (gum  ben- 
zoin 5],  alcohol  f-5vj);  the  alcohol  evaporates  and  leaves  a  smooth,  glazed 
surface.  Dr.  Dudgeon  recommends  as  a  varnish  a  solution  of  gum 
damar  §j,  rectified  benzoline  f§vj.  When  the  tracing  is  likely  to  be 
subjected  to  friction,  a  second  or  third  coat  should  be  applied  subse- 
quently. 

Explanation  of  the  Normal  Pulse-tracing. 

With  each  contraction  of  the  left  ventricle  a  volume  of  blood  is 
forced  into  the  aorta,  which  distends  it,  the  distending  impulse  being 
transmitted  by  a  wave-like  motion  to  remote  arteries.  This  distending 
impulse  lifts  the  button  of  the  lever  sharply  upward,  forming  the  so- 
called  percussion  up-stroke,  a  b;  but  the  distending  impulse  is  exag- 
gerated by  the  system  of  levers,  and  having  been  thrown  up  too  high 
the  lever  falls  by  its  own  weight  too  low,  so  that  it  is  again  caught  and 
lifted  by  the  tidal  blood,  forming  the  tidal  wave,  c  d  e.  The  gradual 
descent  of  the  lever  is  again  interrupted  at  e  f  g,  forming  a  wave,  called 
the  dicrotic  wave,  due  to  the  recoil  of  the  blood  from  the  closure  of 
the  aortic  valves.     (Fig.  84.) 

b 


Fig.  84. 


'{J 

e 

a  b,  percussion  up-stroke  ;  a  b  c,  percussion  wave ;  c  d  e,  tidal  wave ;  e  f  g,  dicrotic  wave ; 
d  ef,  aortic  notch ;  /  g,  diastolic  period. 

Roy  and  Aclami  believe  that  the  apex  (h,  b,  d)  of  the  percussion-wave 
is  due  to  the  sudden  pulling  down  of  the  auriculo-ventricular  valves 
by  the  papillary  muscles  during  the  first  rapid  part  of  their  contrac- 
tion.     Hence  they  call  the  wave  the  " papillary  wave." 

The  second  wave  (c,  d,  e)  corresponds  in  time,  they  say,  with  the 
outflow  from  the  ventricle  due  to  the  continued  contraction  of  the  heart- 
wall  and  papillary  muscles  after  the  flaps  have  been  pulled  down. 
Hence  they  prefer  to  call  this  wave  the  "outflow  remainder,"  instead 
of  ' '  tidal ; '  wave. 

Interpretation  of  Pulse-tracings.  Sphygmographic  tracings 
must  be  interpreted  in  accordance  with  the  known  peculiarities  of  the 
patient,  his  history,  and  the  associated  physical  signs. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     399 

1.  The  Amplitude.  The  height  of  the  percussion-stroke  varies  con- 
siderably in  health.  It  is  increased  in  conditions  which  bring  about  1<  in- 
tension and  rapid  systolic  contractions  of  the  heart.  Heuce  the  febrile 
pulse  is  usually  one  of  considerable  amplitude.  It  is  increased  also  very 
markedly  in  aortic  regurgitation.  Suddenness  of  systole  rather  than 
force  determines  the  height  of  the  up-stroke  (see  Fig.  85). 

Fig.  85. 


Tracing  from  a  case  of  aortic  regurgitation. 

2.  Obliquity  of  the  Pereussion-stroke.  Normally  the  percussion-stroke 
ascends  vertically  from  the  base-line.  A  tendency  to  incline  forward 
indicates  a  weak  and  laboring  heart,  or  an  aneurism  interposed  betwi  en 
the  radial  artery  and  the  heart.  In  the  latter  case  there  is  also  a  ten- 
dency to  rounding  of  the  summit  of  the  percussion-wave,  and  the 
up-stroke  is  generally  short.  There  is  usually  also  irregularity  in 
successive  pulsations,  some  showing  the  gradual  ascent  and  rounded 
summit  much  better  than  others.  Sometimes,  however,  when  aneu- 
rism exists,  there  is  no  evidence  of  it  in  the  tracing,  and  differences 
upon  the  two  sides  are  not  always  significant  (see  Fig.  86). 


Fig.  86. 


Tracing  from  a  case  of  aneurism  of  the  aorta. 

Disease  at  the  aortic  orifice  and  the  intervention  of  a  considerable 
quantity  of  subcutaneous  fat  or  of  any  growth  superficial  to  the  vessel 
may  cause  a  marked  obliquity  of  the  percussion-stroke.  Sansom  asserts 
that,  such  causes  excluded,  as  well  as  aneurism  and  organic  disease  of 
the  aorta  and  its  valves,  a  sloping  line  of  ascent,  observed  under  vari- 
ous gradations  of  pressure,  indicates  feebleness  of  the  left  ventricle. 
He  considers  it  of  higher  diagnostic  value  than  irregularity,  which  he 

saws  is  often  neurotic. 

Fig 


From  a  case  of  aortic  stenosis,  showing  increased  tension  and  the  pulsus  bisft  rii  "•-■. 

3.  Increased  Breadth  of  the  Apex  of  the  Percussion-wave.  The 
breadth  of  the  apex  of  the  percussion-wave  indicates  the  time  during 
which  the  artery  is  kept  full  by  the  systole  of  the  left  ventricle.  When 
the  left  ventricle  acts  slowly  and  forcibly  the  arteries  will  be  kept  dis- 
tended  for  a  longer  time,  and  this  distention  will  be  manifest  in  broad- 


400 


SPECIAL  DIAGNOSIS. 


ening  of  the  apex  of  the  tracing  (see  Fig.  87).  The  degree  of  disten- 
tion of  the  artery  is  called  tension,  hence  a  broadening  of  the  apex  is 
an  evidence  of  high  tension.  As  the  word  "  high"  does  not  indicate 
the  duration  of  the  tension,  Sansom  has  very  properly  suggested  that 
we  should  speak  of  persistent  high  tension  as  "prolonged"  tension. 
This,  then,  is  the  significance  of  the  broad  top  of  the  tracing.    (Fig.  88.) 

Fig.  8S. 


From  a  case  of  mitral  stenosis,  showing  increased  tension  and  some  irregularity. 

Prolonged  arterial  tension  occurs  when  there  is  a  strong  heart  acting 
slowly,  a  large  volume  of  blood,  or  obstruction  in  the  capillary  circula- 
tion.    (For  specific  causes,  see  under  Tension.) 

The  amount  of  pressure  required  to  develop  the  characteristics  of  a 
pulse,  and  still  more,  the  amount  required  to  obliterate  it,  are  good 
indexes  of  the  degree  of  tension  present.  Some  pulses,  however,  appear 
to  the  touch  to  be  of  prolonged  tension,  but  a  sphygmogram  does  not 
show  it.  Such  cases  are  often  explained  by  the  fact  that  the  heart  has 
begun  to  fail  under  the  strain  put  upon  it  by  prolonged  obstruction  in 
the  capillaries.  There  may  be  regurgitation  also  from  the  mitral  or 
aortic  orifice. 

4.  Acute  Angle  of  the  Percussion-wave.  When  the  heart's  action 
is  feeble  or  sudden,  the  volume  of  blood  small,  or  the  resistance  in  the 
capillaries  much  diminished,  the  up-stroke  of  the  tracing  is  vertical, 
and  the  down-stroke  forms  an  acute  angle  with  it.  The  dicrotic  wave  is 
pronounced,  and  often  descends  unduly  low,  sometimes  to  the  base-line. 
These  are  the  characteristics  of  low  tension  (see  Fig.  89).  When  the 
dicrotic  wave  springs  from  a  lower  level  than  the  base-line  of  the 
tracing  it  is  hyperdicrotic.  When  the  dicrotic  wave  is  wholly  effaced 
in  the  succeeding  up-stroke  it  is  monocrotic. 


Low  tension  with  irregularity,  from  cases  of  mitral  regurgitation. 

While  dicrotism  is  commonly  associated  with  low-tension  j>ulses,  it 
is  occasionally  met  with  also  in  high-tension  pulses.  Sansom  says, 
however,  that  he  has  scarcely  ever  observed  the  conjunction  of  broad 
summit  and  marked  dicrotism  without,  the  patient's  manifesting  the 
signs  of  failing  heart. 

5.  Irregularity  of  the  Base-line.  This  occurs  normally  in  some 
persons  as  the  result  of  respiration,  especially  deep  breathing.  It  occurs 
in  respiratory  diseases  also,  and  in  affections  causing  dyspnoea.  De- 
cided undulation  of  the  base-line,  the  curves  being  irregular,  occurs  in 
tubercular  meningitis. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     401 

6.  Differences  in  the  Height  of  Successive  Percussion-waves  or  in 
their  Distance  from  Each  Other.  These  are  written  evidences  of  dis- 
turbance in  the  rhythm  of  the  heart.  The  first  expresses  irregularity 
in  volume  of  successive  beats,  and  the  second  irregularity  in  time. 
When  this  latter  amounts  to  the  omission  of  a  beat  it  is  called  intermis- 
sion.    All  these  changes  are  shown  in  Fig.  90. 

Fig.  90. 


From  a  case  of  advanced  mitral  stenosis,  showing  extreme  irregularity  and  intermission. 


Auscultation.  The  stethoscope  should  always  be  used  in  examin- 
ing the  arteries.  The  double  stethoscope  is  preferable,  as  strong  pres- 
sure must  be  avoided  upon  the  vessels.  When  the  single  stethoscope 
is  used  some  diagnostic  value  attaches  to  the  character  of  the  shock 
that  is  transmitted  to  the  head.  The  arteries  open  to  auscultation  are 
the  carotids  when  the  neck  is  slightly  extended;  the  subclavian;  the 
innominate  above  the  sterno-clavicular  articulation;  the  brachial  artery 
in  the  bend  of  the  elbow,  with  the  arm  slightly  extended  ;  and  the 
crural  artery  just  below  Poupart's  ligament.  The  normal  systolic  and 
diastolic  heart-sounds  are  heard  in  the  carotid  and  subclavian  arteries. 
The  systolic  sounds  may  be  heard  over  the  abdominal  aorta,  due  to 
tension  of  the  vessels.  The  diastolic  sound  is  rarely  heard  in  this  situ- 
ation. In  the  other  vessels  no  sounds  are  heard.  Pressure-murmur. 
By  pressure  with  the  stethoscope  over  one  of  the  vessels  its  calibre  is 
modified  and  a  murmur  created.  This  murmur  corresponds  in  time 
with  the  pulse,  hence  is  systolic  in  time,  and  increases  or  diminishes 
in  intensity,  depending  upon  the  amount  of  pressure  placed  upon  it. 
Just  here  may  be  mentioned  the  systolic  humming  which  is  heard  in 
children  between  the  third  month  and  the  sixth  year  over  the  fonta- 
nelles  and  sometimes  over  the  rest  of  the  head.  Osier  long  ago  called 
attention  to  the  murmur  and  pointed  out  its  lack  of  significance  in  the 
diagnosis  of  hydrocephalus. 

Abnormal  Sounds.  Abnormal  sounds  or  murmurs  are  due  to 
alterations  of  the  blood,  disease  outside  of  the  vessels  causing  pressure, 
and  disease  of  the  vessels.  Murmurs  from  disease  of  the  vessels,  as 
the  aorta,  are  discussed  under  the  head  of  arterio  sclerosis  or  aneurism. 

Murmurs  may  be  propagated  into  the  arteries.  A  systolic  murmur 
created  at  the  aortic  orifice  may  be  heard  in  the  vessels  of  the  neck  and 
along  the  aorta.  On  the  other  hand,  in  aortic  regurgitation,  the  dias- 
tolic sound  normal  in  the  carotid  and  subclavian  disappears,  and  the 
diastolic  murmur  is  not  heard. 

Double  Sounds  of  the  Vessels.  Double  sounds  are  sometimes  heard 
in  the  crural  artery  under  the  following  circumstances  :  (1)  In  aortic 
insufficiency  ;  (2)  in  mitral  stenosis  ;  (3)  in  lead-poisoning  ;  (4)  in 
pregnancy.  Duroziez's  double  murmur,  heard  when  greater  pressure  is 
used   by  the  stethoscope,  occurs  in  aortic   regurgitation   when   there  is 

26 


402  SPECIAL  DIAGNOSIS. 

good  compensation.  Many  authorities  refer  to  this  as  a  valuable  diag- 
nostic sign  in  this  affection.  The  double  sound  in  all  instances  occurs 
with  large  and  quick  pulse.  It  is  probably  caused  by  sudden  collapse 
of  the  artery,  and  the  reflux  blood-current  which  is  possibly  an  aortic 
regurgitation. 

Murmurs  due  to  Alterations  of  the  Blood.  They  are  gen- 
erated in  anaemia  and  chlorosis.  They  are  called  functional  murmurs 
to  distinguish  them  from  murmurs  due  to  disease  of  the  vessels.  They 
are  systolic  in  time.  They  are  soft  and  low  in  pitch,  often  of  a  musi- 
cal character.  The  degree  of  loudness  may  vary  with  the  position  of 
the  patient.  They  are  increased  by  excitement.  The  intensity  of  the 
murmur  increases  in  the  course  of  fevers.  Murmurs  in  the  vessels, 
apparently  of  functional  origin,  are  sometimes  heard.  The  vessels  are 
dilated  from  actual  disease.  The  increased  calibre  favors  the  develop- 
ment of  a  murmur  by  the  creation  of  a  fluid  vein.  Dilatation  of  the 
innominate  artery  sometimes  takes  place,  giving  rise  to  a  murmur, 
which  in  loudness  and  character  simulates  the  murmur  of  aneurism.  A 
functional  murmur  is  sometimes  heard  in  the  vessels,  independently  of 
disease,  in  cases  of  aortic  regurgitation.    The  murmur  is  systolic  in  time. 

Pressure-murmurs.  Pressure  of  the  stethoscope,  or  that  caused 
by  diseases  outside  of  the  bloodvessels.  When  heard  over  the  subclavian 
artery,  the  pressure-murmur  may  be  due  to  adhesions  or  consolidation  at 
the  apex  of  the  lung.  It  is  more  frequently  heard  at  the  left,  and  may 
be  only  present  during  full  expansion  of  the  lung.  It  is  due  to  tem- 
porary pulling  or  bending  of  the  artery  during  deep  breathing.  -  When 
it  occurs  on  both  sides  it  is  not  of  much  significance.  Murmurs  in 
the  axillary  artery,  or  in  any  arteries  surrounded  by  enlarged  lymphatic 
glands,  are  created  by  their  pressure.  Murmurs  in  the  thyroid  gland 
have  been  referred  to  (see  Goitre). 

Brain-murmurs.  A  systolic  murmur  is  heard  over  the  anterior 
fontanelle  and  the  temporal  region  in  healthy  children  prior  to  the 
fifth  year.  It  is  of  more  frequent  occurrence  in  rickets  than  in  any 
other  condition. 

Murmurs  due  to  Disease  of  the  Arteries.  In  the  aorta  the 
murmurs  are  due  to  aneurism  or  atheroma,  or  both.  In  the  smaller 
vessels  both  conditions  may  be  present,  although  atheroma  is  the  usual 
one.  The  murmur  is  systolic  in  time,  rough  in  character,  strong  or 
weak.      It  is  associated  with  other  signs  of  atheroma. 

Percussion.  Percussion  is  applicable  to  disease  of  the  aorta  only. 
The  methods  by  which  it  is  conducted  and  the  result  of  the  examina- 
tion will  be  considered  in  the  section  on  Aneurism. 

The  Veins. 

Diseases  of  the  veins  are  largely  surgical  and  do  not  frequently  come 
under  the  notice  of  the  physician.  Alterations  in  the  veins  from  physi- 
cal causes  in  the  circulation,  local  or  general,  are  of  frequent  observation 
and  are  of  the  greatest  diagnostic  significance.  The  "venous  phe- 
nomena" are  physiological  and  pathological  evidences  of  the  circula- 
tion of  the  blood  in  the  veins. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     403 

Examination  is  limited  largely  to  the  jugular  veins  in  general  affec- 
tions of  the  circulation ;  to  other  subcutaneous  veins  in  addition  in 
local  affections.  The  examination  is  made  by  inspection  to  determine 
the  size  and  degree  of  pulsation  of  the  veins  ;  by  palpation  to  confirm 
the  results  of  inspection  and  to  determine  the  presence  of  a  thrill ;  by 
auscultation  to  determine  the  presence  of  murmurs. 

Inspection.  A.  Increased  fulness  or  enlargement  of  the  veins.  The 
change  in  size  may  be  general  or  local.  In  both  instances  there  is 
interference  with  the  venous  return  of  blood. 

1.  General  increase  in  fulness  may  be  observed  in  all  the  veins,  but 
is  most  pronounced  and  more  readily  studied  in  the  jugular  veins  of 
the  neck.  Associated  with  the  enlargement,  general  venous  engorge- 
ment is  observed,  and  hence  oedema  (which  obscures  external  veins), 
cyanosis,  effusions  in  serous  cavities,  and  congestion  of  internal  organs 
attend  the  pathological  venous  phenomena.  1 1  must  follow  that  a  central 
disturbing  influence  upon  the  circulation  is  present,  and  so  we  find 
interference  with  the  circulation  in  the  right  heart  to  be  the  causal 
factor.  This  interference  is  due  to  dilatation  of  the  right  auricle  and 
ventricle,  which  in  turn  may  have  arisen  from  valvulitis,  myocarditis, 
pericarditis,  or,  on  account  of  increased  pulmonic  blood-pressure, 
from  emphysema  and  other  pulmonary  obstructions.  In  rare  instances 
pressure  upon  the  cava?  by  a  mediastinal  tumor  may  cause  general 
over-fulness  of  the  veins. 

The  jugular  veins.  The  jugular  veins,  both  internal  and  external, 
are  seen  to  be  distended,  even  in  stout  people.  The  observation  can 
better  be  made  by  viewing  the  head  when  it  is  turned  to  the  opposite 
side  from  the  vein  which  is  under  examination.  The  external  jugular 
can  almost  always  be  seen ;  the  internal  jugular  frequently  when  en- 
gorged. They  may  also  be  felt  under  these  circumstances.  The  posi- 
tion of  the  veins  can  be  more  readily  distinguished  by  observing  their 
relation  to  the  sterno-cleido-mastoid  muscle.  The  internal  jugular  vein 
is  seen  in  the  intersterno-cleido-mastoid  fossa,  just  behind  the  sterno- 
clavicular articulation.  Here  the  jugular  bulb  is  seen,  and  at  this 
point  in  the  veins  the  bulbar  valves  are  situated.  When  abnormally 
full  it  may  project  beyond  the  surface  and  rise  one-fourth  or  one-half 
inch  above  the  articulation.  The  over-fulness  is  more  marked  in  the 
dorsal  than  in  the  upright  posture. 

Local  increase  in  fulness.  Local  increase  in  fulness  of  the  veins  is 
due  to  narrowing  or  closure  of  the  venous  trunk  by  pressure  or  by 
thrombosis.  A  mediastinal  tumor  pressing  upon  the  cava  will  cause 
abnormal  fulness  of  the  jugulars.  The  veins  of  the  skull  become  dis- 
tended and  tortuous  in  thrombosis  of  the  longitudinal  sinus.  Enlarge- 
ment of  the  veins  of  the  armor  leg  points  to  compression  or  thrombosis 
of  the  axillary  or  femoral  vein  respectively.  The  enlargement  is 
associated  with  oedema  of  the  respective  extremity.  Enlargement  of 
the  superficial  veins  of  the  thorax  is  seen  in  intra-thoracic  pressure 
from  tumor  or  aneurism,  rarely  in  dilatation  of  the  heart.  Enlarge- 
ment of  the  veins  of  both  legs  may  be  due  to  obstruction  of  the  vena 
cava  or  both  iliac  veins.  The  latter  is  liable  to  occur  in  pelvic  tumors. 
When  there  is  engorgement  of  the  portal  vein  collateral  circulation  is 


404  SPECIAL  DIAGNOSIS. 

frequently  carried  on  through  the  abdominal  veins.  The  veins  are 
enlarged ;  and,  in  some  instances,  the  veins  about  the  navel  enormously 
distended,  because  of  a  permanent  patulous  umbilical  vein.  The  crown 
of  veins — caput  Medusce — is  significant  of  cirrhosis  of  the  liver  and 
of  partial  thrombosis.  Enlargement  of  the  veins  of  the  extremities, 
from  the  causes  above  mentioned,  must  not  be  confounded  with  the 
unilateral  or  bilateral  varicosity  that  occurs  after  pregnancy,  after  pro- 
longed intra-abdominal  pressure  from  other  causes,  or  in  inflammation 
of  the  veins  in  the  course  of  septic  diseases,  as  typhoid  fever. 

B.  Pulsation  of  the  veins.  The  circulation  in  the  veins  differs  from 
that  in  the  arteries.  The  blood-flow  is  continuous.  Two  circumstances 
modify  it — respiratory  movements  and  cardiac  action. 

Pulsation  due  to  Respiratory  Movements.  The  modification  is  particu- 
larly seen  in  the  veins  of  the  neck.  During  inspiration,  all  of  the  veins 
empty  rapidly,  while  in  forced  expiration,  or  with  strong  effort,  as  seen 
in  coughing,  the  discharge  from  the  veins  is  checked  and  they  become 
full  and  even  over-distended.  When  the  fulness  of  the  veins  is  normal 
the  respiratory  alterations  are  not  observed,  except  the  swelling  that 
occurs  in  severe  coughing,  as  in  whooping-cough.  When  they  are 
abnormal,  as  from  right-sided  cardiac  dilatation  (q.  v.),  they  show  a 
corresponding  to-and-fro  swelling  synchronous  with  respiratory  move- 
ments. Upon  coughing,  the  jugular  bulb  may  appear  as  a  rounded 
pulsating  bunch  between  the  heads  of  the  sterno-mastoid  muscle.  The 
internal  jugular  may  also  swell  and  contract.  Increased  pulsation  with 
fulness  of  the  veins  is  seen  during  the  labored  expiration  of  asthma 
and  emphysema. 

Abnormal  respiratory  movements.  Alteration  of  the  respiratory  move- 
ments is  observed  in  cases  of  pericarditis  or  of  mediastino-pericarditis. 
Normally  the  vessels  are  drawn  upon  and  bent  during  the  act  of  in- 
spiration— inspiratory  collapse.  In  the  above  pathological  conditions 
they  swell  up  in  inspiration  and  empty  duriug  expiration,  directly 
opposite  to  the  normal  state. 

Pulsation  due  to  Cardiac  Movements.  The  Venous  Pulse.  The  car- 
diac movements  also  modify  the  movements  of  the  blood  in  the  veins. 
They  cause  rhythmical  pulsation,  or  the  venous  pulse.  This  may  be 
communicated  from  the  carotids  underneath  or  occur  in  the  veins. 
The  so-called  true  and  false  pulses  are  thus  produced.  The  true  venous 
pulse  is  divided  into  the  (1)  negative  and  (2)  positive  pulse,  the  former 
being  the  pulse  of  health,  the  latter  the  pathological  venous  pulse. 

1.  The  normal  or  negative  venous  pidse  is  so  designated  because  it  is 
not  due  to  positive  action  of  the  heart,  causing  retrogression  of  blood. 
It  can  be  demonstrated  by  pressure  of  the  finger  on  the  middle  of  the 
veins.  Pulsation  ceases  below  because  the  blood  does  not  regurgitate 
from  the  heart ;  it  does  not  pulsate  above,  or  the  pulsation  lessens  mate- 
rially, indicating  non-transmission  from  the  carotid.  The  negative 
venous  pulse  is  presystolic  in  time  and  can  only  be  seen  in  the  external 
jugulars.  The  vein  collapses  during  the  systole  and  distends  or  pulsates 
before  the  systole,  hence  is  presystolic.  This  may  be  observed  by 
inspection,  keeping  in  view  also  at  the  same  time  the  apex  or  carotid 
pulse.     The  systolic  collapse  occurs  quickly.     The  presystolic  pulsa- 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     405 

tion  follows  slowly,  with  an  appreciable  interval  between  the  two- 
The  presystolic  distention  occurs  during  the  time  that  the  auricle  is 
filled  with  blood  ;  the  collapse  occurs  when  the  auricle  is  empty — that 
is,  during  the  ventricular  systole.  When  the  auricle  is  distended  the 
flow  of  blood  from  the  veins  is  impeded,  and  hence  the  jugulars  are 
overfilled.  When  the  auricle  is  empty  the  flow  of  blood  from  the 
veins  is  favored,  hence  the  vein  collapses  (the  systole). 

Diagnosis.  It  may  be  distinguished  from  pulsation  in  the  artery 
by  the  time,  by  the  greater  size  of  the  surface-pulsation,  on  account 
of  the  greater  size  of  the  vein,  by  the  impression  of  undulation  rather 
than  shock  received  by  the  finger,  by  the  impression  of  passive  force 
rather  than  of  active  power.  Sometimes  it  is  extremely  difficult  to 
recognize  the  normal  or  negative  venous  pulse  on  account  of  undula- 
tions in  the  veins  produced  by  the  blood-flow  and  transmitted  carotid 
impulse. 

2.  The  positive  venous  pulse  is  systolic  in  time.  It  is  due  to  positive 
action  of  the  heart.  It  is  pathognomonic  of  tricuspid  regurgitation 
(q.  v.).  When  the  right  ventricle  contracts  the  regurgitant  blood- 
wave  is  transmitted  into  the  cava  through  the  incompetent  valves. 
It  appears  first  in  the  internal  jugulars  or  their  bulbs,  because  of  the 
direct  course  of  the  innominate  and  right  jugular  from  the  cava.  Sub- 
sequently the  left  may  become  affected.  If  the  valve  in  the  vein  is 
competent,  the  systolic  regurgitant  wave  is  seen  there  only.  The  pul- 
sation of  the  enlarged  bulb  is  seen  in  the  intersterno-cleido-mastoid 
fossa.  Usually  the  valve  is  insufficient,  or  rapidly  becomes  so,  and 
the  systolic  back-wave  therefore  extends  upward.  The  same  wave  is 
transmitted  to  the  veins  of  the  liver,  causiug  systolic  swelling  and  dias- 
tolic collapse  of  the  liver.  These  conditions  are  produced,  as  previ- 
ously mentioned,  in  right-sided  dilatation  of  the  heart,  providing  there 
are  moderate  force  and  slowness  of  the  heart's  action.  When  the  heart 
becomes  very  weak  and  rapid  the  pulsations  disappear. 

Diagnosis.  1.  The  negative,  true,  or  normal  pulse  is  distinguished 
from  the  pathological  or  positive  pulse,  and  from  the  transmitted  pulsa- 
tion, by  its  time.  It  is  timed  by  the  apex-beat,  or  the  carotid  puis;) 
of  the  opposite  side.  The  negative  pulse  (normal)  is  presystolic,  the 
collapse  of  the  vein  systolic  ;  the  positive  pulse  (pathological)  is  systolic 
in  time.  The  patient  should  hold  his  breath,  as  increased  respiratory 
movement  will  modify  the  venous  pulsation.  2.  The  imparted  or  false 
pulse  is  transmitted  from  the  carotids,  and  can  be  recognized  by  stopping 
the  flow  of  blood  by  pressing  the  finger  or  barrel  of  the  stethoscope  on  the 
vein  in  the  middle  of  the  neck,  after  it  has  been  emptied  by  pressure 
upward.  If  the  pulsation  is  communicated  (false  pulse),  the  vein 
remains  empty  in  the  portion  nearest  the  heart,  and  fills  up  in  the 
peripheral  portion,  while  the  pulsation  ceases  toward  the  centre  (below) 
and  increases  in  the  periphery  (above  the  finger).  If  the  carotid 
artery  is  pressed  upon  as  near  the  heart  as  possible,  the  transmitted 
pulse  will  cease.  In  the  positive  pulse  the  portion  near  the  heart 
slowly  fills  from  below  upward. 

In  congenital  heart  disease  with  patulous  foramen  ovale  the  positive 
venous  pulse  may  sometimes  be  seen,  but  is  extremely  rare. 


406  SPECIAL  DIAGNOSIS. 

Diastolic  collapse  is  seen  in  pericarditis,  as  observed  by  Friedreich. 
The  collapse  occurs  at  the  time  of  the  cardiac  diastole.  It  is  dis- 
tinguished from  the  true  pulse  as  follows:  compress  the  jugular  vein, 
pulsation  ceases  above  and  below  the  seat  of  compression. 

Pulsation  of  other  veins.  Quincke  has  described  venous  pulse  in 
the  hand  and  back  of  the  foot,  with  the  capillary  pulse  in  aortic  re- 
gurgitation and  in  anaemia.  It  is  probably  only  the  arterial  pulse 
propagated  through  the  capillaries.  The  positive  pulse  may  be  seen 
in  the  veins  of  the  face,  in  the  cutaneous  veins  of  the  arm  and  hand, 
and  in  the  superficial  mammary  veins,  and  in  the  veins  of  the  leg. 

Thrombosis  of  the  Veins.  This  is  usually  detected  by  palpa- 
tion, and  occurs  most  frequently  in  the  femoral  vein.  The  vein  is 
transformed  into  a  firm,  round  cord,  and  is  distinguished  from  the  artery 
by  the  absence  of  pulsation.  Thrombosis  in  these  veins  and  in  the 
iliac  veins  higher  up  occurs  in  acute  infectious  diseases  and  in  the  debility 
of  the  aged.  Dropsy  in  the  area  of  distribution  of  the  veins  is  per- 
ceived. 

Auscultation.  In  health  no  sounds  are  heard.  Two  conditions 
contribute  to  the  creation  of  a  murmur  in  the  veins  :  1,  change  in  the 
character  of  the  blood  ;  2,  dilatation  with  the  occurrence  of  positive 
venous  pulse. 

The  Venous  Hum.  In  anaemia  and  chlorosis,  and  sometimes  in  healthy 
patients,  a  hum  or  murmur,  or  buzzing  sound  is  heard  over  the  jugular 
veins.  It  is  louder  on  the  right  side  than  on  the  left.  It  is  soft  and 
low  in  pitch,  and  may  be  musical  ;  it  has  been  described  as  humming 
or  whizzing.  It  is  continuous.  For  its  detection  a  double  stethoscope 
should  be  used,  as  pressure  increases  it,  and  the  patient  should  not  turn 
the  head  to  one  side,  as  it  is  increased  when  this  position  is  taken.  The 
murmur  is  modified  by  the  respiration  and  by  the  cardiac  action.  It 
is  louder  in  deep  inspiration  when  the  blood  is  going  more  rapidly  to 
the  thorax.  It  is  also  louder  in  the  upright  position.  It  is  frequently 
louder  during  the  diastole.  The  increased  loudness  at  these  periods 
occurs  because,  from  the  sucking  action  during  inspiration  and  during 
the  diastole,  the  blood  is  more  rapidly  drawn  toward  the  heart.  The 
murmur  is  caused  by  the  flow  of  blood  from  the  narrow  jugular  into 
its  wider  bulb,  producing  a  fluid  vein.  Later  authorities  believe  it  to 
be  due  to  lateral  vibration  of  the  walls  of  the  veins.  Similar  murmurs 
are  heard  in  other  veins,  as  in  those  of  the  extremities  when  the  anaemia 
is  profound.  They  are  stronger  during  the  diastole  of  the  heart. 
The  venous  hum  is  sometimes  heard  at  the  lower  border  of  the  liver, 
to  the  right  of  the  median  line,  in  cirrhosis  of  the  liver.  It  is  created 
in  the  enlarged  collateral  veius.  It  may  be  modified  by  pressure  of 
the  stethoscope.  It  may  be  heard  in  this  situation  in  emaciated  and 
cachectic  subjects  not  the  subject  of  cirrhosis.  The  venous  hum  may 
be  heard  in  the  innominate  veins  (first  and  second  interspaces  and  right 
costo-clavicular  articulation),  in  the  subclavian  and  axillary  veins. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     407 

The  Data  Obtained  by  Inquiry. 

The  Subjective  Symptoms  of  Heart  Disease. 

A.  Symptoms  referred  to  the  Heart.  1.  Pain.  Although 
pain  in  the  region  of  the  heart  may  be  a  symptom  of  disease  of  that 
organ  or  of  the  pericardium,  in  the  large  majority  of  instances  it  is  due 
to  other  causes.  The  physician  is  frequently  consulted  by  the  anxious 
patient  on  account  of  pain,  other  than  heart-pain,  but  referred  to  this 
region,  or  more  precisely  to  the  fifth  or  sixth  interspace  on  the  left 
side.  The  causes  of  such  pain  are  various  :  1,  neuralgia  ;  2,  pleuro- 
dynia ;  3,  myalgia  ;  4,  local  pleurisy  ;  5,  periostitis.  The  neuralgias 
may  be  associated  with  points  of  tenderness,  which  are  usually  the  seat 
of  the  greatest  intensity  of  the  pain.  These  poiuts  of  tenderness  cor- 
respond with  the  positions  at  which  the  nerves  have  their  exit  through 
the  fascia  to  the  surface,  and  are  found  along  the  sternum,  in  the  course 
of  the  mid- axilla,  and  along  the  vertebrae.  The  pain  is  paroxysmal, 
occurs  at  variable  periods  of  the  day,  and  in  anaemic  subjects  or  in  the 
course  of  neurasthenia.  It  may  precede  the  development  of  herpes 
zoster.  In  these  cases  the  exact  nature  of  the  pain  is  not  known  until 
the  eruption  appears.  In  gout  or  diabetes  we  may  have  local  neuritis, 
which  causes  neuralgic  pain  in  this  situation. 

Pleurodynia,  which  is  thought  to  be  an  affection  of  the  pleural 
nerves,  is  more  general.  The  pain  is  increased  by  pressure  of  the 
finger-tips,  although  it  is  not  localized.  It  is  relieved  by  pressure  of 
the  whole  hand.  In  myalgia,  which  is  seen  so  frequently  in  phthisis 
on  account  of  severe  coughing,  in  rheumatism  and  in  debilitated  sub- 
jects generally,  the  pain  is  more  or  less  diffuse,  interferes  more  or  less 
with  movements  of  the  chest,  is  relieved  by  uniform  general  pressure, 
and  is  usually  associated  with  myalgia  in  other  organs.  .  The  pain  of 
pleurisy  is  recognized  by  the  fact  that  it  usually  inhibits  the  act  of 
breathing  and  is  associated  with  cough,  and  because  friction-sounds  may 
be  detected.  Periostitis.  In  disease  of  the  ribs  of  the  prsecordia  the 
pain  is  associated  with  tenderness  and  swelling.  One  or  more  of  the 
costo- sternal  articulations  may  be  extremely  tender.  The  pain  and 
tenderness  are  due  to  the  periostitis  of  syphilis  or  to  that  which  follows 
typhoid  fever.  In  one  of  my  oases  the  rib  had  to  be  resected.  It 
may  be  due  to  the  internal  pressure  and  erosion  of  ribs  in  aneurism. 
The  same  affection  may  cause  neuralgic  pains  in  the  nerves.  Abscess. 
Pain  in  this  region  may,  in  rare  instances,  be  due  to  localized  tubercu- 
lous abscess  between  the  pericardium  and  the  walls  of  the  thorax.  One 
such  case  was  under  my  care.  The  abscess  developed  secondarily  to 
empyema  and  occupied  the  precordial  region,  causing  bulging.  The 
pain  was  intense,  and  was  only  relieved  after  the  caseating  pus  was 
removed  by  incision. 

Pain  in  the  epigastrium  is  often  held  to  be  due  to  cardiac  disease.  It 
is  usually  due  to  gastralgia,  or,  as  it  is  sometimes  termed,  cardialgia. 
It  is  recognized  by  the  location  of  the  pain  and  its  association  with  gas- 
tric symptoms,  as  flatulency,  weight,  fulness,  and  acidity.  In  gastric 
ulcer  the  epigastric  pain  is  localized,  accompanied  by  tenderness  on 


408  SPECIAL  DIAGNOSIS. 

pressure,  and  is  increased  by  food.  However,  acute,  severe  and  ex- 
cruciating pain  in  the  epigastrium  may  be  due  to  rupture  of  the  heart 
and  also  to  pericarditis. 

Pain  in  Disease  of  the  Pericardium.  Pain  in  the  region  of  the  heart 
is  sometimes  due  to  affections  of  the  pericardium.  Pericarditis  is  the 
most  common.  While  centralized  in  the  heart-region,  it  may  radiate 
to  the  left  shoulder  and  extend  down  the  arm.  It  is  paroxysmal  and 
may  have  some  of  the  characters  of  angina.  It  is  increased  by  move- 
ment, by  pressure,  and  by  the  action  of  the  diaphragm.  The  patient 
is  often  obliged  to  sit  up  in  bed  and  suffers  from  orthopnoea.  It  may 
be  referred  to  the  epigastrium.  A  pericardial  friction-sound  is  usually 
detected.  Pain  due  to  disease  of  the  aorta.  Acute  inflammation  of  the 
aorta  is  also  the  cause  of  cardiac  paiu.  The  pain  exteuds  along  the 
course  of  the  aorta,  may  be  referred  to  the  sternum,  and  extends  along 
the  spine.  The  pain  is  severe,  causing  an  anxious  countenance  and  an 
expression  of  extreme  suffering.  In  gouty  subjects  with  atheroma  pain 
may  occur  in  this  situation  in  paroxysms.  There  is  usually  valvular 
disease  at  the  aortic  orifice.  Similar  pain  occurs  in  syphilis  and  in 
alcoholic  subjects,  and  may  be  due  to  malaria.  It  is  a  visceral  neurosis, 
or  a  form  of  neuralgia. 

Pain  in  the  region  of  the  heart  is  frequently  due  to  aneurism.  The 
pain  is  usually  due  to  pressure  of  the  aneurism  upon  adjacent  structures. 
If  it  presses  on  the  bone  and  causes  erosion,  the  pain  is  of  a  boring 
character,  localized  at  one  point.  It  has  been  previously  referred  to. 
In  aneurism  alone,  without  pressure,  the  pain  is  of  a  dull  aching  char- 
acter, increased  by  movement,  relieved  by  rest,  or  by  change  of  posi- 
tion. When  nerves  are  pressed  upon,  pain  may  be  acute  and  of  a 
neuralgic  nature.  It  may  follow  the  course  of  the  nerves  and  be 
associated  with"  numbness  or  sensations  of  tingling.  The  long  duratiou 
of  the  pain,  its  localization,  and  its  aching  character  are  sufficient  to 
exclude  angina  pectoris.  When  the  pain  is  unilateral  it  may  be  due 
to  pressure  of  an  aneurism  upon  the  nerves  at  their  exit  from  the  canal; 
the  pain  extends  along  the  course  of  the  intercostal  nerves.  It  is 
severe  and  burning,  but  there  are  no  localized  points  of  greater  inten- 
sity. The  pain  may  extend  down  the  arms,  and,  when  the  abdominal 
aorta  is  affected,  it  may  extend  down  the  legs.  If  rupture  of  the 
aneurism  takes  place,  the  pain  is  sudden  and  sharp.  Death,  however, 
ensues  quickly,  so  that  the  pain  will  rarely  be  complained  of. 

Pain  in  Disease  of  the  Heart.  Three  forms  are  seen  :  1,  pain  due 
to  disturbances  of  the  rhythm  ;  2,  pain  due  to  valvular  disease  ;  3, 
pain  due  to  angina  pectoris. 

Disturbance  of  the  Rhythm.  Palpitation,  intermission,  ancT  irregu- 
larity of  the  heart  occur  in  the  large  majority  of  cases  without  pain. 
Paroxysms  of  palpitation  are  sometimes  attended  with  severe  precor- 
dial pain  and  distress.  This  occurs  in  the  reflex  palpitation,  which, 
as  will  be  seen,  is  due  to  disease  in  other  situations  ;  in  the  palpitation 
of  Graves'  disease  and  of  anaemia.  The  palpitation  of  organic  disease 
is  induced  by  exertion.  The  rapid  action  of  the  heart  is  painful  and 
the  throbbing  is  complained  of  as  causing  distress. 

While  intermission  and  irregularity  may  continue  without  pain  at 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     409 

times,  the  patient  is  conscious  of  this  disturbance  of  the  rhythm,  and 
complains  of  the  stoppage,  which  then  is  attended  by  distress,  some- 
times amounting  to  severe  pain.  This  is  particularly  the  case  when 
the  heart-action  is  tumultuous,  as  the  disturbance  of  rhythm  seen  in 
pericarditis  and  in  valvular  disease. 

Pain  due  to  Valvular  Disease.  In  disease  of  the  aortic  valves  pain 
is  of  more  frequent  occurrence  than  in  other  valvular  lesions.  It  is 
usually  complained  of  in  the  region  of  the  aorta  at  the  base  of  the 
heart,  and  is  aggravated  by  exertion  (see  Atheroma). 

Pain  due  to  Angina  Pectoris  Heberden  was  the  first  to  describe 
the  attacks  of  angina  pectoris,  which,  in  its  typical  form  and  in  associ- 
ation with  disease  of  the  heart,  is  not  of  common  occurrence.  The 
pain  of  angina  is  severe  and  is  associated  with  the  most  intense  anguish. 
It  comes  on  suddenly,  and  may  occur  in  paroxysms.  The  patient 
realizes  that  the  pain  is  in  the  heart,  and  complains  of  feeling  as  if  the 
organ  were  held  in  a  vise.  From  the  heart  it  radiates  to  the  neck  and 
down  the  arms.  It  extends  particularly  to  the  left  arm,  and  may  be 
severe  in  the  wrist  or  in  the  ends  of  the  fingers.  With  the  pain  there 
is  a  sense  of  impending  death,  with  sinking  and  depression.  The  pain 
lasts  but  a  few  seconds  or  minutes,  and  during  that  time  the  face  of  the 
patient  becomes  pale  or  of  an  ashy  hue,  perspiration  breaks  out  on  the 
forehead,  the  extremities  become  cold,  the  breathing  is  short.  Prostra- 
tion usually  follows  the  attack,  but  the  precordial  distress  disappears 
entirely.  The  attack  may  occur  in  patients  who  are  entirely  free  from 
organic  disease  of  the  heart.  It  is  most  commonly,  however,  associated 
with  some  lesion.  The  lesions  frequently  found  are  disease  of  the  cor- 
onary arteries,  atheroma  of  the  aorta,  aortic  valve  disease,  and  myo- 
carditis with  fatty  degeneration.  It  occurs  after  middle  life,  and  is 
more  frequent  in  males.  It  may  occur  without  exciting  cause,  or  fol- 
low undue  exertion,  exposure  to  cold,  mental  excitement,  or  profound 
emotion.  The  points  upon  which  the  diagnosis  is  based  are  :  1.  The 
seat  of  the  pain.  This  is  usually  behind  the  middle  or  the  lower  part 
of  the  sternum,  and  more  to  the.  left  than  to  the  right.  Thence  it 
extends  to  the  posterior  portion  of  the  axilla  or  it  may  radiate  up  to 
the  neck.  In  some  instances  it  extends  to  the  occiput.  Frequently 
the  pain  extends  to  the  left  arm  as  far  as  the  elbow  or  even  the  fingers. 
It  may  extend  to  the  abdomen  or  to  the  right  arm.  I  have  seen  it  affect 
both  arm*.  It  is  not  influenced  by  external  pressure.  2.  The  sense 
of  constriction  with  the  indescribable  torture  are  most  characteristic. 
3.  The  respirations  are  shallow,  or  may  even  cease,  but  there  is  no 
dyspnoea.  4.  The  patient  is  terrified  and  restless.  5.  The  pale  face, 
extremely  anxious  countenance,  the  cold  sweat  on  the  forehead,  make 
a  striking  picture,  which  when  once  seen  can  never  be  forgotten.  6. 
Such  extreme  depression  and  sensation  of  impending  death  occur  in  no 
other  affection.  Particularly  characteristic  is  the  immediate  relief, 
without  hysterical  manifestations  or  dyspeptic  symptoms  of  any  kind, 
which  follows  an  attack.  7.  During  the  attack  the  frequency  of  the 
pulse  is  not  much  influenced,  and  the  action  of  the  heart  may  be  uni- 
form and  regular.  Rarely  its  frequency  may  be  lessened.  The  tension 
of  the  pulse  is  increased  during  the  attack. 


410  SPECIAL  DIAGNOSIS. 

Some  authors  speak  of  various  grades  of  angina,  and  call  all  forms 
of  precordial  pain  and  oppression,  with  radiation  of  the  pains  to  the 
arms  and  neck,  mild  forms  of  angina.  Such  attacks  have  often  obvi- 
ous causes  in  disturbance  of  digestion  and  in  emotional  excitement. 
When  associated  with  increased  arterial  tension  and  signs  of  arterio- 
sclerosis, they  may  be  of  an  anginoid  nature.  The  greatest  difficulty 
exists  in  distinguishing  them  from  pseudo-angina.  Hysterical  or 
pseudo  angina  can  be  distinguished  only  with  extreme  difficulty.  It 
occurs  much  more  frequently  than  true  angina.  One  attack  seems  to 
predispose  to  others.  It  occurs  in  females  who  present  other  symptoms 
of  hysteria.  It  occurs  usually  before  forty  years  of  age.  The  attacks 
most  frequently  come  on  at  night,  and  may  be  periodical.  They  are 
particularly  associated  with  menstrual  disorders.  The  pain  is  less  severe 
and  the  oppression  is  not  so  marked  in  pseudo-angina  ;  coldness  of  the 
hands  and  feet,  with  the  occurrence  of  syncope,  or  a  general  feeling 
of  sinking,  are  common  symptoms.  The  pain  is  of  long  duration  and  is 
associated  with  great  agitation.  It  is  preceded  by  neuralgia,  and  neural- 
gic pains  persist  after  the  attack.  Low  tension,  feeble  second  sound, 
and  soft  arteries  may  be  present,  although  the  opposite  is  also  seen. 
The  disease  is  never  fatal.  In  one  of  niy  patients  attacks  of  hysterical 
hemoptysis  alternated  with  the  anginal  attacks. 

2.  Palpitation.  In  palpitation  the  patient  is  conscious  of -the 
action  of  the  heart.  Although  it  may  occur  in  organic  disease,  it  is 
more  frequently  due  to  disease  outside  of  the  heart. 

Symptoms.  The  symptoms  vary  in  degree.  In  mild  forms  the 
patients  may  complain  of  a  flattering  or  a  sensation  of  sinking  in  the 
precordial  region.  In  the  more  severe  forms  the  heart  beats  violently 
against  the  chest.  The  arteries  throb,  the  action  of  the  heart  is  increased, 
and  the  area  of  impulse  against  the  chest-wall  is  enlarged  and  visible. 
The  patient  complains  of  distress  in  the  precordial  region.  The  pulse 
may  be  increased  to  150.  In  nervous  palpitation  the  face  becomes 
flushed,  aud  after  the  attacks  large  quantities  of  urine  are  passed. 
Sometimes,  in  this  form  of  palpitation,  exertion  relieves  the  attack. 
On  examination,  the  sounds  are  found  to  be  normal,  but  they  are  clear 
and  metallic  in  character.  The  diastolic  sounds  are  greatly  accentuated. 
If  anemia  is  present,  murmurs  due  to  that  condition  are  increased  in 
intensity.    The  attack  may  last  but  a  few  minutes  or  continue  for  hours. 

(ft)  It  is  most  common  in  cases  in  which  the  nervous  system  generally 
is  in  a  state  of  increased  excitability.  Attacks  occur  at  puberty  and 
at  the  menopause.  It  is  very  common  in  hysteria  and  neurasthenia. 
It  follows  emotional  disturbance.      It  is  more  frequent  in  women. 

(6)  It  is  due  to  the  action  of  the  toxic  substances,  as  tobacco,  tea  and 
coffee,  and  alcohol. 

(c)  From  strain  and  overexertion,  particularly  if  associated  with 
excitement,  palpitation  may  occur  and  continue  for  a  long  period. 
This  is  the  form  of  irritable  heart  described  by  Da  Costa,  common  in 
young  soldiers  during  the  war. 

(d)  In  valvular  disejse  of  the  heart  when  compensation  fails,  and  in 
myocarditis,  attacks  of  palpitation  occur,  distinctly  from  exertion. 

:>.  Intermission  and  Irregularity.    When  the  patient  feels  the 


DISEASES  OF  HEART,  BLOODVESSELS,  AXD  MEDIASTINUM.     4H 

alteration  in  rhythm,  it  is  usually  due  to  nervous  disturbance.  In 
organic  disease  it  is  not,  as  a  rule,  appreciated  by  the  patient.  Although 
not  a  subjective  symptom  alone,  it  may  be  well  to  speak  of  irregularity 
in  this  connection. 

Arrhythmia  is  the  general  term  applied  to  irregularity  of  the  action 
of  the  heart.  When  the  heart  intermits — that  is,  when  one  or  two 
beats  are  dropped  at  intervals  of  half  a  minute,  a  minute,  or  longer  ; 
wheu  the  beats  are  unequal  in  volume  and  force,  or  occur  at  unequal 
distances  in  time,  the  heart's  action  is  irregular.  The  causes  of  dis- 
turbance of  the  rhythm  have  been  classified  by  Baumgarten1  as  fol- 
lows :  1.  Central  causes  in  the  medulla  either  from  organic  disease,  as 
hemorrhage  or  concussion,  or  from  physical  influences.  2.  Reflex 
influences,  as  in  dyspepsia  and  diseases  of  the  liver,  lungs,  and  kidneys. 
3.  Toxic  influences — tobacco,  coffee,  and  tea  are  common  causes  ;  vari- 
ous drugs,  such  as  digitalis,  belladonna,  and  aconite.  4.  Changes  in 
the  heart  itself.  Mural  changes,  as  in  dilatation,  fatty  degeneration, 
and  myocarditis  ;  changes  in  the  cardiac  ganglia  ;  sclerosis  of  the  cor- 
onary arteries. 

It  must  not  be  forgotten  that  both  irregularity  and  intermittency  may 
occur  in  persons  otherwise  in  good  health,  and  continue  for  a  long 
period  of  time  without  any  evidence  of  arterial  or  cardiac  disease. 
(For  the  varieties  of  arrhythmia,  see  The  Pulse.) 

B.  Symptoms  referred  to  the  Circulation.  1.  Pulsation 
of  the  Arteries.  Pulsation  of  the  arteries,  especially  the  carotids,  the 
abdominal  aorta,  and  the  brachial  arteries,  occurs  in  anaemia  and  is 
common  in  emotional  disturbances.  Such  pulsation,  as  of  the  abdom- 
inal aorta,  may  be  reflex  from  organic  disease  in  the  vicinity.  Similar 
localized  pulsation  in  the  innominate  arteries  may  be  mistaken  for 
aneurism.  The  pulsation  that  attends  organic  heart  disease  may  be 
due  to  hypertrophy  of  the  heart,  but  is  particularly  characteristic  of 
aortic  regurgitation. 

2.  Hemorrhages.  In  the  description  of  valvular  lesions  it  will  be 
seen  that  hemorrhages  from  the  lungs  occur  quite  frequently  in  disease 
of  the  mitral  valve.  The  hemorrhage  may  be  due  to  congestion,  to 
actual  rupture  of  the  vessels,  or  to  hemorrhagic  infarct  (see  Pulmonary 
Hemorrhage).     It  may  simulate  hemorrhage  due  to  tubercul<>~i>. 

•').  Cyanosis.  Cyanosis  is  a  symptom  of  common  occurrence  in  the 
course  of  organic  heart  disease  (see  page  72). 

4.  Dropsy  (see  page  92).  The  dropsy  of  heart  disease  occurs  after 
failure  in  compensation  in  the  course  of  valvular  disease,  and.  in  dila- 
tation of  the  heart.  It  may  disappear  entirely,  if  the  conditions  arc 
improved,  or  become  permanent  and  progressive.  In  general,  it  may 
be  said  to  lie  distinctly  a  phenomenon  of  mitral  regurgitation  ami  sec- 
ondary tricuspid  regurgitation.  It  occurs  in  a  lesser  degree  in  mitral 
obstruction,  and  still  less  in  disease  at  the  aortic  orifice. 

C.  Symptoms  referred  to  the  Luxgs.  The  chief  subjective 
symptom  is  dyspnoea.  Dyspnoea,  due  to  disease  of  the  heart,  i-  clin- 
ically divided  into  (1)  dyspnoea  caused,  or  increased  by  exertion j  (_) 

1  See  Transactious  of  the  Association  of  American  Physicians,  vol.  Hi. 


412  SPECIAL  DIAGNOSIS. 

paroxysmal  dyspnoea  ;  (3)  orthopnoea  ;  (4)  rhythmical  dyspnoea,  or 
Cheyne-Stokes  respiration.  The  dyspnoea  of  effort  comes  on  after 
the  slightest  exertion.  In  paroxysmal  dyspucea  the  attack  comes  on 
without  apparent  cause.  It  must  be  distinguished  from  the  paroxys- 
mal dyspnoea  of  asthma  or  emphysema.  The  physical  signs  of  lung 
disease  usually  point  to  the  latter.  The  paroxysmal  dyspnoea  of  heart 
disease  is  attended  by  more  violent  efforts  in  breathing  than  the  phys- 
ical state  of  the  lungs  admits,  and  the  difficulty  attends  both  inspira- 
tion and  expiration.  Wheezing  is  not  so  marked  as  in  forms  of  asthma. 
There  is  some  obstruction  to  the  outgoing  of  air,  but,  on  account  of  air- 
hunger,  all  the  efforts  of  the  patient  are  exerted  to  fill  the  chest.  In 
paroxysmal  dyspnoea  the  breathing  usually  becomes  quiet  if  the  patient 
is  placed  in  a  comfortable  position,  provided  there  is  no  lung  or  pleural 
complication.  The  position  does  not  modify  the  severe  dyspnoea  of 
asthma  or  emphysema.  Orthopuoea  has  been  described  previously  (see 
page  293).     (For  Cheyne-Stokes  respiration,  see  page  248.) 

Cough.  Cough  is  of  frequent  occurrence  in  heart  disease.  The 
causes  are  various.  It  may  be  due  to  pressure  upon  the  bronchus  or 
the  pneumogastric  nerves,  as  in  pericardial  effusion.  It  may  be  due  to 
the  congestion  of  the  lungs  which  occurs  in  failing  compensation.  A 
low-grade  bronchitis  may  develop  on  account  of  passive  congestion, 
causing  cough.  If  hemorrhagic  infarcts  take  place,  cough  may  be 
present.  It  attends  the  broncho-pneumonia  that  follows.  In  the 
cough  that  occurs  from  pressure  of  an  aneurism,  a  metallic  brassy 
cough  is  created,  which  occurs  in  paroxysms  and  may  be  associated 
with  alterations  in  the  voice.  The  clanging  cough  may  result  in  the 
expectoration  of  blood-tinged  sputum  which  is  frequently  due  to  the 
gradual  rupture  of  the  aneurism. 

D.  Symptoms  referred  to  the  Brain.  The  symptoms  are 
usually  due  to  disturbance  of  the  cerebral  circulation,  because  either 
an  insufficient  quantity  of  blood  or  improperly  oxygenated  blood  is 
supplied  to  the  brain.  Vertigo,  faintness,  and  languor  are  complained 
of  in  the  first  instance.  Dulness,  stupor,  and  moderate  delirium  may 
occur  in  the  later  stages  in  the  second  instance.  In  the  course  of 
organic  heart  disease  epilepsy  or  epileptiform  convulsions  may  arise  on 
account  of  embolism  or  thrombosis.  Chorea  is  of  common  occurrence, 
and  frequently  arises  from  the  same  causes  as  the  organic  disease. 
Coma  in  the  course  of  heart  disease  may  be  due  to  hemorrhage  into 
the  brain,  embolism,  or  to  thrombosis.  Hemorrhage  occurs  in  patients 
in  whom,  at  the  same  time,  there  are  usually  found  hypertrophy  of  the 
left  ventricle,  atheroma  of  the  artery,  and  renal  disease.  Embolism 
occurs  in  valvular  disease,  particularly  in  aortic  regurgitation  and  mitral 
obstruction.  With  or  without  coma  we  may  have  the  occurrence  of 
paralysis  for  the  same  reason. 

Thrombosis  in  the  course  of  heart  disease  is  usually  due  to  disease  of 
the  bloodvessels  rather  than  disease  of  the  heart  itself,  although  a  weak- 
ening of  the  heart,  as  in  dilatation,  is  a  factor  predisposing  to  the  devel- 
opment of  thrombosis. 

E.  Symptoms  referred  to  the  Alimentary  Canal.  In  the 
course  of  organic  heart  disease  dyspepsia  and  forms  of  gastritis  are  of 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     413 

common  occurrence.  Patients  complain  of  indigestion  of  various  forms, 
or  of  nausea  and  vomiting.  While  water-brash  and  flatulence  are 
caused  primarily  by  the  condition  of  the  heart,  they  may  in  their  turn 
cause  symptoms  of  palpitation  and  cardiac  distress.  These  gastric 
difficulties  are  more  particularly  seen  in  diseases  of  the  auriculo- 
ventricular  valves  and  are  associated  with  congestion  and  secondary 
cirrhosis  of  the  abdominal  viscera. 

F.  Symptoms  referred  to  the  Throat.  The  patient  may  com  • 
plain  of  pain  in  the  throat.  This  may  be  paroxysmal,  and  is  some- 
times said  to  be  due  to  angina  pectoris.  Hoarseness  or  modifications 
of  the  voice  are  occasional  symptoms  of  pericarditis.  They  are  of  fre- 
quent occurrence  in  the  course  of  aneurism  due  to  pressure  upon  the 
recurrent  laryngeal  nerves. 

G.  Symptoms  referred  to  the  Kidneys.  The  kidneys  are 
intimately  related  with  the  heart  at  a  distant  point  in  the  circulation, 
and  are  the  frequent  seat  of  changes  due  primarily  to  disease  of  the 
central  organ  of  circulation.  The  changes  in  the  urine  will  be  referred 
to  again  ;  suffice  it  to  say  that  in  the  course  of  mitral  and  tricuspid 
disease  and  dilatation,  scanty  urine,  of  high  color,  loaded  with  urates, 
containing  a  small  amount  of  albumin,  is  quite  common  and  indicative 
of  passive  congestion  of  the  kidney.  It  may  result  in  cyanotic  indu- 
ration or  interstitial  nephritis.  On  the  other  hand,  the  urine  may  be 
of  low  specific  gravity  and  pale  in  color.  There  may  or  may  not  be 
traces  of  albumin.  The  change  is  due  to  a  granular,  contracted  kidney, 
which  is  associated  with  hypertrophy  of  the  left  ventricle  and  arterial 
sclerosis.  Bloody  urine  is  usually  due  to  renal  embolism  when  it  occurs 
suddenly  in  the  course  of  organic  heart  disease.  It  may  be  due  to  the 
emboli  that  are  found  in  septic  endocarditis.  Renal  disease  in  all  forms 
may  complicate  disease  of  the  heart  (see  Kidney  Disease). 

The  Subjective  Symptoms  of  Arterial  Disease. 

The  patient  may  complain  of  an  increased  amount  of  blood  in  a 
part,  or  of  a  lessened  amount.  Thus  the  symptoms  of  anaemia  in  a 
part,  as  vertigo  and  giddiness,  or  of  flashes  of  light,  may  attract  atten- 
tion (see  Cerebral  Thrombosis).  All  the  symptoms  of  deficient  supply 
of  blood  to  the  brain  may  be  present.  The  feet  are  cold  for  the  same 
reasons.  The  diseased  vessels  prevent  the  blood  from  reaching  the 
area.  Pain  is  common  only  when  atheroma  or  aneurism  i>  presenl 
(q.  v.).  Throbbing  or  pulsation  is  complained  of.  It  may  be  a  strik- 
ing feature  of  hysteria  and  neurasthenia.  The  abdominal  aorta  is  fre- 
quently thus  affected.  The  pulsation  may  be  constant  or  intermittent. 
There  may  be  dyspeptic  symptoms.  The  pulsation  of  the  carotids 
may  cause  abnormal  sensations  in  the  head,  and  the  beating  transmitted 
to  the  ear  be  a  source  of  extreme  annoyance. 

Pericarditis. 

Inflammation  of  thr  Pericardium.  The  inflammation  may  be 
acute  or  chronic.  It  is  also  divided  according  to  the  nature  of  the 
inflammation  into  simple  fibrinous  inflammation  and  inflammation  with 


414  SPECIAL  DIAGNOSIS. 

effusion.  The  effusion  may  be  serous,  bloody,  or  purulent,  depending 
upon  the  nature  of  the  inflammation.  Pericarditis,  either  acute  or 
chronic,  is  also  divided  into  primary  or  secondary  pericarditis.  The 
primary  form  is  of  extremely  rare  occurrence.  Indeed,  it  may  well 
be  doubted  whether,  in  common  with  the  inflammations  of  serous 
membranes  in  general,  pericarditis  is  ever  primary,  or  so-called  idio- 
pathic, in  origin. 

1.  The  cause  may  be  local.  Extension  of  the  inflammation  from 
tissues  in  the  vicinity  is  a  common  cause  of  pericarditis.  It  may  follow 
a  pleurisy  and  partake  of  the  nature  of  the  primary  pleural  inflamma- 
tion. It  often  attends  empyema,  either  from  extension  of  the  infection 
to  the  pericardium  or  from  rupture  into  the  pericardial  sac.  It  may 
follow  all  forms  of  inflammation  of  the  mediastinum.  Disease  of  the 
ribs  adjacent  to  the  pericardium  may  set  up  pericarditis.  Inflammations 
below  the  diaphragm  frequently  give  rise  to  pericarditis.  Peritonitis, 
when  general  or  local;  sub-diaphragmatic  abscess;  suppurative  gas- 
tritis, with  perforation  of  the  stomach  ;  abscess  of  the  liver  ;  sup- 
purating hydatid,  and  other  forms  of  suppuration  below  the  diaphragm, 
belong  to  the  latter. 

2.  Pericarditis  in  General  Diseases.  The  general  diseases  which 
cause  inflammation  of  the  pericardium  are  those  which  usually  give 
rise  to  inflammation  of  serous  membranes.  They  are :  Infectious 
diseases,  particularly  scarlet  fever,  measles,  erysipelas,  and  typhoid 
fever.  All  forms  of  septicaemia  may  be  attended  by  inflammation  of 
the  pericardium.  Tuberculosis  is  a  frequent  cause,  of  pericarditis. 
Inflammation  of  this  membrane  frequently  arises  in  the  course  of 
rheumatism.  It  may  occur  in  the  course  of  the  disease,  or  attend 
some  of  the  affections  which  are  themselves  manifestations  of  rheu- 
matism, such  as  acute  tonsillitis.  In  the  course  of  certain  dyscrasise 
the  pericardium  is  frequently  the  seat  of  inflammation.  This  is  par- 
ticularly the  case  in  scurvy.  It  occurs  also  in  Bright' s  disease  and 
may  be  the  first  manifestation  to  the  patient  of  this  disease.  This  is 
particularly  the  case  in  the  chronic  form  of  Bright' s  disease.  It 
occurs  in  the  course  of  gout.  Age.  The  various  forms  of  pericar- 
ditis may  occur  at  any  age,  although  that  which  attends  scarlatina 
and  rheumatism  occurs  in  early  life,  while  late  in  life  it  is  an  attendant 
upon  chronic  Bright' s  disease  and  gout. 

While  rarely  an  attendant  upon  diseases  of  the  heart,  except  as  a 
coincidence,  it  is  said  to  occur  after  ulcerative  endocarditis,  after  myo- 
carditis, and  during  the  course  of  aneurism  of  the  aorta. 

Acute  Fibrinous  or  Plastic  Pericarditis.  This  is  probably  the 
most  common  form  that  is  seen.  It  is  the  variety  that  particularly  at- 
tends Bright' s  disease,  rheumatism,  and  tuberculosis.  It  may  be  want- 
ing entirely  in  symptoms.  An  examination  of  the  heart  in  the  routine 
of  duty  may  reveal  its  presence  by  physical  signs.  In  the  course  of  the 
primary  causal  disease,  if  the  temperature  rises  a  little  higher  than  it 
should,  or  convalescence  is  delayed,  pericarditis  should  be  suspected. 
Again,  if  the  pulse  is  more  rapid  and  quicker  than  customary  at  the 
period  of  disease  the  examination  is  made,  or  out  of  proportion  to  the 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     415 

temperature,  the  disease  should  be  suspected.  There  may  be  altered 
rhythm  or  tumultuous  action.  In  other  instances  the  patient  may 
complain  of  pain  in  the  region  of  the  heart.  It  is  usually  localized  iu 
the  fourth  or  fifth  interspace.  It  is  not  very  severe  and  not  influenced 
by  pressure.  Sometimes  the  pain  is  complained  of  at  the  xiphoid 
cartilage.  In  rare  instances  it  may  resemble  angina.  The  pain  and 
the  occurrence  of  fever  further  call  attention  to  the  heart. 

Physical  Signs.  Inspection.  Nothing  unusual  is  observed, 
although  the  heart  may  be  seen  to  beat  more  violently  against  the  chest- 
wall.     The  impulse  is  diffused. 

Palpation.  A  friction-fremitus  may  be  detected,  due  to  the  rub- 
bing together  of  the  roughened  pericardial  surfaces.  It  is  not  always 
present.  It  may  be  felt  when  the  whole  hand  is  laid  over  the  prse- 
cordia,  or  by  palpation  with  the  tips  of  the  fingers.  It  is  most  marked 
over  the  right  ventricle,  particularly  in  the  fourth  interspace,  and  is 
increased  when  the  patient  leans  forward. 

Auscultation.  A  friction-sound  is  usually  present.  It  may  be 
present  while  the  fremitus  is  absent ;  but,  on  the  other  hand,  if  the 
fremitus  is  present,  we  can  always  hear  the  friction.  It  is  heard  over 
the  region  where  the  fremitus  is  felt.  Character.  It  is  a  to-and-fro 
rubbing,  scratching,  or  grating  sound  ;  it  gives  the  impression  of  being- 
near  the  ear.  It  may  be  modified  by  the  pressure  of  the  stethoscope  and 
by  the  position  of  the  patient.  It  may  be  heard  in  the  erect  and  dis- 
appear in  the  recumbent  posture.  Position.  It  is  localized  and  not 
transmitted  away  from  the  heart.  It  may  be  heard  along  the  course 
of  the  sternum.  It  is  usually  heard  in  the  third  or  fourth  interspace, 
but  may  be  heard  as  high  as  the  second,  adjacent  to  the  sternum  in 
either  interspace.  Sometimes  it  is  heard  at  the  second  costal  cartilage 
on  the  right,  rarely  at  the  apex.  The  point  of  maximum  intensity  may 
vary  with  the  position  of  the  patient.  Time.  It  is  both  systolic  and 
diastolic.  In  some  cases  it  may  be  only  systolic  in  time,  or  it  may  be 
of  a  galloping  nature,  representing  three  sounds  during  the  cardiac 
cycle.  Again,  the  to-and-fro  sound  is  not  synchronous  with  the  sys- 
tolic and  diastolic  sound,  although  it  occurs  but  once  in  the  cardiac- 
cycle.  It  may  begin  after  systole,  and  be  completed  before  the  end  of 
the  diastole.  The  impression  that  it  is  a  superadded  sound  is  most 
positive. 

Diagnosis.  Acute  pericarditis  without  effusion  is  not  recognized 
generally,  because  it  has  not  been  sought  for.  In  the  larger  number  of 
cases,  as  previously  intimated,  there  have  been  no  indications  of  disease 
of  the  pericardium  during  life.  If  sought  for,  however,  the  diagnosis 
is  usually  easy.  The  pericardial  friction  may  be  mistaken  for  an 
organ ir  /icarl-innrintir  or  for  pleural  or  pleuro- pericardial  friction.  It 
is  often  difficult  to  distinguish  the  to-and-fro  friction  from  the  mur- 
murs of  double  aortic  disease.  If  attention  is  paid  to  the  general  and 
local  phenomena,  the  mistake  is  not  likely  to  be  made.  The  location 
of  the  murmurs  in  organic  heart  disease,  the  direction  of  the  transmis- 
sion, the  character  of  the  murmur,  the  peculiar  character  of  the  pulse, 
and  the  secondary  effects  upon  the  muscles  of  the  heart,  point  to  the 
diagnosis  of  valvular  lesion.     The  pleuro-pericardial   friction   which 


416  SPECIAL  DIAGNOSIS. 

simulates  pericardial  friction  usually  occurs  in  the  course  of  phthisis 
or  pleuro-pneumonia.  It  is  modified  by  respiratory  movement :  (1)  It 
may  disappear,  or  at  least  diminish,  if  the  breath  is  held  ;  (2)  a  full 
expiration  may  cause  its  disappearance.  While  it  is  of  cardiac  rhythm 
it  is  modified  by  the  respiratory  rhythm,  so  that  on  inspiration  it  is 
usually  more  marked.  The  pleuro  pericardial  friction  is  not  strikingly 
modified  by  position.  Pleural  Friction.  This  is  of  respiratory  rhythm 
and  ceases  with  cessation  of  breathing.  The  pericardial  friction  per- 
sists even  if  the  breath  is  held. 

Pericarditis  "with  Effusion.  I  know  of  no  affection  which  is  more 
frequently  overlooked  during  life  than  pericardial  effusion.  This  is 
because  it  develops  without  symptoms.  In  plastic  pericarditis  we  have 
referred  to  the  occurrence  of  pain.  This  may  occur  before  the  effusion 
in  the  latter  form,  but  is  usually  moderate.  As  with  dry  pericarditis, 
however,  it  may,  in  rare  instances,  be  very  severe,  anginous  in  char- 
acter, and  be  increased  by  pressure  over  the  heart  or  on  the  pit  of  the 
stomach. 

The  symptoms  are  usually  due  to  the  special  character  of  the  inflam- 
mation and  the  presence  of  fluid  in  the  pericardium. 

1.  General  Symptoms.  In  non-suppurative  cases  the  symptoms 
are  usually  cerebral.  Delirium  may  be  moderate  or  maniacal.  It 
must  not  be  confounded  with  the  delirium  which  occurs  in  the  course 
of  acute  rheumatism  with  hyperpyrexia.  In  addition,  choreiform 
movements  have  been  described.  They  may,  however,  be  of  rheumatic 
origin.  Other  cerebral  symptoms,  as  hemiplegia  and  convulsive  attacks 
in  the  course  of  pericarditis,  are  probably  due  to  an  associated  endocar- 
ditis, causing  embolism,  the  endocarditis  not  having  been  recognized. 
In  some  cases  albuminuria  is  found. 

The  general  phenomena  that  attend  pericardial  effusion  depend  upon 
the  nature  of  the  primary  disease  and  the  character  of  the  fluid.  In 
tuberculous  pericarditis,  emaciation,  irregular  fever,  sweats  and  prostra- 
tion ensue.  In  purulent  pericarditis  there  may  be  recurring  chills 
with  a  temperature-range  decidedly  intermitting,  along  with  other 
phenomena  of  purulent  accumulation.  In  a  case  recently  seen  the 
patient  was  extremely  debilitated  and  prostrated  on  account  of  pneu- 
monia following  influenza.  He  was  extremely  ansemic,  and  the  blood- 
count  showed  diminution  of  red  cells  of  one-half  without  other  partic- 
ular change.  Every  fourth  day  after  a  chill  the  temperature  would 
rise  to  103°  or  104°.  A  friction-sound  was  detected  after  the  second 
chill.  It  disappeared,  but  the  physical  signs  of  effusion  could  not  be 
well  made  out.  From  the  first  the  heart's  action  was  so  weak  that 
the  sounds  were  scarcely  discernible.  At  the  autopsy  four  or  five 
ounces  of  pus  were  found  in  the  pericardial  sac,  the  purulent  accumu- 
lation in  this  situation  being  the  only  lesion  to  account  for  the  symp- 
toms. 

2.  Local  Symptoms.  The  local  symptoms  are  due  to  the  accumu- 
lation of  fluid  within  the  pericardium.  Dysjmoea  is  the  most  common. 
The  degree  depends  upon  the  amount  of  effusion.  If  the  latter  is  large, 
there  may  be  extreme  orthopnoea  ;  if  the  effusion  is  present  for  a  con- 


DISEASES  OF  HEART,  BLOODVESSELS,  AXD  MEDIASTINUM.     417 


siderable  time,  it  may  give  rise  to  no  symptoms.  Dysphagia.  In 
large  effusions  this  may  occur  on  account  of  pressure  upon  the  oesoph- 
agus. Altered  Cardiac  Rhythm.  The  effect  of  the  effusion  upon  the 
heart  is  to  interfere  with  its  action,  which,  although  usually  regular, 
becomes  on  the  slightest  exertion  or  the  least  excitement  irregular  or 
subject  to  severe  attacks  of  palpitation.  The  heart's  action  is  increased 
in  frequency;  when  the  effusion  is  very  large  it  may  be  not  only  irreg- 
ular, but  also  intermittent.  Aphonia  may  occur  from  pressure  upon 
the  recurrent  laryngeal  nerve.  Cough  of  an  irritative  character  is 
sometimes  noted.      The  jiulsus  paradoxus  may  be  present. 

3.  Physical  Signs.  Inspection.  There  is  bulging  of  the  prsecor- 
dia,  particularly  in  children.  The  ribs  and  interspaces  are  prominent. 
In  adults  the  interspaces  are  even  with  or  distended  beyond  the  surface 
of  the  ribs,  and  they  are  sometimes  widened.  The  enlargement  may 
extend  to  the  antero-lateral  region  of  the  left  chest.  The  large  effu- 
sion interferes  with  expansion  of  the  lung  on  the  left  side,  and  hence 
movement  is  diminished.  In  such  cases  the  epigastrium  may  be 
prominent  on  account  of  displacement  downward  of  the  diaphragm 
and  liver.  The  apex-beat  is  absent  or  faintly  seen,  displaced  upward 
and  to  the  left.  The  apex- beat  does  not  extend  as  near  the  left  border 
of  dulness  as  in  dilatation.  It  may  be  seen  in  the  fourth  interspace, 
or  a  faint  impulse  may  be  observed  in  the  second  and  third  interspaces 
beyond  the  midclavicular  line. 

Palpation.  The  impulse  is  feeble  and  diminishes  progressively  as 
the  effusion  increases.  The  position  of  the  apex  determined  by  inspec- 
tion is  confirmed.  Ewart  points  out  that  the  first  rib  is  palpable  at  its 
sternal  attachment  in  pericardial  effusion.  The  pericardial  friction 
which  may  have  been  present  at  first  disappears  with  the  effusion. 
Fluctuation  may  be  detected  in  large  effusions.  In  large  effusions  the 
liver  is  depressed  and  readily  palpable. 

Fig.  91. 


Percussion-dulness  in  pericardial  effusion  ;  the  lower  and  left  margins  left  undefined,  owing  to 
their  having  been  inseparable  from  the  dull  percussion  of  the  abdomen  and  of  the  left  pleura. 
(Gairdner.) 

Percussion.     The  area  of    precordial  dulness  is  increased.      There 
is  increase  of  the    lateral    boundaries  and  great  increase  of  absolute 

•27 


418  SPECIAL  DIAGNOSIS. 

dulness  over  the  sternum.  The  increase  of  area  is  usually  in  all 
directions,  although  increase  of  the  dulness  upward  and  to  the  left  only 
is  very  common.  It  may  extend  as  high  as  the  second  rib.  As  pointed 
out  by  Rotch,  dulness  of  the  triangle  in  the  fifth  right  interspace  formed 
by  the  right  border  of  the  heart  and  the  right  lobe  of  the  liver,  is 
common  in  effusion.  It  may  be  the  earliest  sign  of  effusion.  Ebstein 
calls  this  region  the  car dio- hepatic  triangle,  and  points  out  that  the  dul- 
ness is  absolute  in  effusion,  although  impaired  in  normal  states  from  the 
liver.  Pulmonary  resonance  is  modified  posteriorly  in  large  effusions. 
The  dulness  in  large  effusion  includes  the  axillary  region,  so  that  it 
may  simulate  a  pleural  effusion.  The  dulness,  however,  does  not 
extend  below  the  eighth  rib  in  this  region,  whereas,  iu  pleural  effusion, 
dulness  always  extends  to  the  bottom  of  the  pleural  sac.  In  a  large 
pericardial  effusion  the  semilunar  space,  or  Traube's  line,  is  obliterated. 

Auscultation.  On  auscultation  the  sounds  are  feeble  and  distant. 
They  may  be  scarcely  heard  at  all  over  the  precordial  region.  The 
sounds  at  the  base  of  the  heart  are  diminished  in  intensity.  If  a  fric- 
tion-sound was  heard  at  the  beginning,  it  disappears  entirely  as  the 
effusion  is  poured  out.  In  moderate  effusions  the  friction  may  be  heard 
when  the  erect  posture  is  assumed.  The  change  in  the  rhythm  of  the 
heart  which  attends  pericarditis  is  often  marked. 

It  must  not  be  forgotten  that  the  physical  signs,  and  especially  the 
change  in  impulse  and  the  area  of  precordial  dulness,  are  modified  by 
the  position  of  the  effusion.  Accumulations  occur  behind  the  heart  or 
above  it,  and  in  these  situations  interfere  least  with  the  displacement 
or  the  enfeeblement  of  the  apex-beat.  The  area  of  dulness,  however, 
is  increased  upward.  In  cases  of  large  effusion  the  compression  of 
the  lung  may  cause  bronchial  breathing  to  be  heard  posteriorly  or  in 
the  axillary  region.  In  a  case  under  my  care  the  diagnosis  of  pericar- 
dial effusion  was  readily  made,  but  the  enormous  effusion  so  markedly 
simulated  an  effusion  into  the  pleural  cavity  that  both  serous  cavities 
were  believed  to  contain  fluid.  Aspiration  was  performed  in  the  sixth 
interspace  in  the  anterior  axillary  line.  The  fluid  was  removed  from 
the  pericardium,  as  was  afterward  determined.  During  life  the  pres- 
sure-signs of  laryngeal  stridor,  difficulty  of  deglutition,  and  extreme 
dyspnoea,  were  present.  Early  vomiting,  epigastric  pain  and  tender- 
ness, slight  delirium,  albuminuria,  and  an  excessively  weak,  rapid 
pulse  occurred  in  the  course  of  the  disease.  The  patient  was  a  male, 
twenty  years  of  age.  The  effusion  was  due  to  tuberculous  pericarditis, 
secondary  to  tuberculosis  of  the  bronchial  gland*.  The  physical  signs 
were  :  prominence  of  the  praecordia,  bulging  of  the  interspaces  on  the 
left  side,  diminished  expansion  of  the  left  side — anteriorly,  laterally, 
and  posteriorly  ;  increased  expansion  at  the  extreme  apex  of  the  lung. 
On  palpation  the  vocal  fremitus  was  absent  below  the  second  interspace 
in  front,  below  the  third  in  the  axilla,  and  diminished  below  the  spine 
of  the  scapula  behind.  On  percussion  there  was  dulness  from  the 
second  left  rib  in  front  to  the  margin  ;  from  the  fourth  to  the  eighth 
rib  in  the  axilla;  below  the  eighth  rib,  tympany.  The  dulness  extended 
beyond  the  margin  of  the  sternum  on  the  right  side,  almost  to  the  right 
nipple-line,  in  the  fourth  and  fifth  interspaces.      Posteriorly,  dulness 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     419 

from  the  middle  of  the  scapula  to  the  base  of  the  thorax,  except  along  the 
vertebrae,  where,  from  the  seventh  to  the  ninth  rib,  there  was  tympany. 
The  physical  signs  of  pericardial  effusion  on  auscultation  were  marked. 
In  the  axilla  the  breath-sounds  were  absent.  There  were  bronchial 
breathing  and  bronchophony  behind  from  the  spine  of  the  scapula  to 
the  base  along  the  vertebrae.  They  were  most  marked  opposite  the 
angle  of  the  scapula  where  the  above-noted  tympany  was  recorded. 
In  the  mid-scapular  line  the  breathing  diminished  from  above  down- 
ward, and  was  absent  at  the  base.  It  is  seen  that  the  physical  signs 
of  pleural  effusion  were  present  posteriorly  and  laterally,  due  to  the 
enormous  effusion.  At  the  autopsy  the  pericardium  was  found  to  con- 
tain sixty-four  ounces  of  fluid.  Pleural  effusion  may  be  excluded  in 
similar  cases  by  the  absence  of  dulness  in  the  axillary  region  below 
the  eighth  rib  ;  by  increase  in  dulness  beyond  the  right  edge  of  the 
sternum  ;  and,  at  the  same  time,  by  the  absence  of  signs  indicating 
dislocation  of  the  heart  to  the  right. 

Diagnosis.  Pericardial  effusion  must  be  distinguished  from  dilata- 
tion of  the  heart.  This  is  not  generally  difficult,  if  the  patient  has 
been  under  observation  during  the  development  of  the  disease.  The 
impulse  is  not  always  absent  in  dilatation  ;  although  feeble  and  diffuse, 
the  expansile  shock  of  the  impulse  is  more  distinct  than  in  dilatation. 
Fluctuation  may  be  detected.  The  area  of  dulness  in  dilatation  does 
not  extend  upward  except  in  cases  in  which  the  right  auricle  is  enlarged. 
The  dulness  does  not  extend  downward  in  dilatation  without  a  similar 
displacement  of  apex-beat  or  of  impulse.  The  shape  of  the  dulness 
differs.  In  dilatation  the  dulness  is  square  in  shape  ;  in  effusion  it  is 
triangular  or  pear-shaped,  with  the  base  downward.  In  dilatation  the 
sounds  are  accentuated,  and  are  of  a  valvular  character  ;  in  effusion  they 
are  muffled.  Dilatation  does  not  cause  the  pressure-symptoms  that 
occur  in  effusion.  In  pericardial  effusion  Bamberger's  sign  is  of  im- 
portance. When  the  patient  is  sitting  upright  an  area  of  dulness  about 
the  size  of  a  silver  dollar  can  be  marked  out  at  the  angle  of  the  scap- 
ula. Over  it,  dulness,  increased  fremitus,  and  bronchial  breathing 
are  made  out.  If  the  patient  leans  forward,  the  dulness  and  the  other 
signs  of  consolidation  disappear,  to  return  when  he  sits  upright.  In 
children  pseudo-pleuritic  signs  are  often  present  posteriorly — dulness, 
pleuritic  friction,  broncho-oegophony — but  will  disappear  if  the  patient 
is  put  in  the  knee-chest  posture.  It  is  of  diagnostic  significance  to 
have  change  of  the  rhythm  and  the  character  of  the  sound  from  day 
to  day,  or  of  its  degree  of  loudness  on  movement  of  the  patient. 

In  pericarditis  with  effusion,  after  its  absorption,  the  friction- sound 
may  return.  Often  it  may  disappear  entirely  and  all  signs  of  peri- 
cardial inflammation  subside.  In  plastic  pericarditis  and  pericardii  is 
with  effusion  adhesion  of  the  two  layers  of  the  pericardium  may  take 
place. 

Effusions  into  the  pericardial  sac  of  serum,  of  blood,  or  of  air,  may 
take  place  without  previous  inflammation. 

Hydro-pericardium.  This  may  occur  in  the  course  of  general 
dropsy  from  kidney  or  heart  disease.  It  may  not  prove  fatal  of  itself, 
but  when  associated  with  effusion  in  the  pleural  sac  it  contributes  to 


420  SPECIAL  DIAGNOSIS. 

the  orthopncea,  on  account  of  which  death  takes  place.  Rarely  after 
scarlet  fever,  effusion  into  the  pericardial  sac  may  be  the  only  dropsical 
symptom.  The  physical  signs  are  those  of  effusion.  It  is  not  attended 
by  fever.  It  is  frequently  overlooked,  because  investigation  beyond 
the  pleura  is  not  made  after  an  effusion  into  that  cavity  has  been 
found. 

ELemo-pericardium.  This  occurs  on  account  of  rupture  of  an 
aneurism  of  the  first  part  of  the  aorta,  of  the  heart  itself,  or  of  the 
coronary  arteries.  Wounds  of  the  pericardium  and  heart  cause  hsemo- 
pericardium.  The  extension  of  the  ulceration  of  malignant  endocar- 
ditis to  the  surface  may  cause  gradual  effusion  of  blood.  The  physical 
signs  are  those  of  effusion.  Death  usually  takes  place  before  there 
has  been  time  to  make  a  sufficiently  accurate  examination  to  determine 
its  presence.  Rapid  heart-failure  due  to  compression  is  the  cause  of 
death.  In  the  case  referred  to  above,  and  in  cases  of  rupture  of  the 
heart,  the  patient  may  live  for  many  hours  with  dyspnoea  and  progres- 
sive weakening  of  the  heart.  In  tuberculosis  and  cancer  the  effusion 
is  frequently  blood-stained. 

Pjseumo-pericardium.  This  occurs  very  rarely,  and  is  due  to 
perforation  from  without  by  a  stab-wound,  or  perforation  from  the 
lung,  oesophagus,  or  stomach.  A  purulent  exudation  may  undergo 
decomposition,  causing  an  accumulation  of  gas.  If  it  arises  from 
perforation,  acute  pericarditis  is  set  up.  The  accumulation  of  gas 
causes  tympany  over  the  movable  area  of  percussion-dulness.  The 
most  striking  sign  is  noted  on  auscultation.  Churning,  splashing,  or 
metallic  sounds  are  heard,  drowning  the  feeble  heart  sounds.  Death 
usually  occurs  quickly. 

Adherent  Pericardium.  Chronic  adhesive  pericarditis  may  fol- 
low the  acute  form  or,  particularly  if  tuberculous,  progress  slowly. 
Inspection  and  palpation.  Indrawing  of  the  interspaces  may  be  seen 
at  the  time  of  the  systole  of  the  ventricles;  even  the  ribs  are  said  to  be 
drawn  in.  This  indrawing  is  most  marked  at  the  apex,  and  must  not 
be  confounded  with  the  retraction  that  occurs  in  the  third  and  fourth 
interspaces  with  the  ventricular  systole.  The  recession  is  synchronous 
with  the  systolic  shock.  In  some  cases  the  systolic  movement  over 
the  prsecordia  is  of  an  undulatory  character.  Walter  Broadbent  calls 
attention  to  systolic  retraction  of  the  back  in  the  region  of  the  eleventh 
or  twelfth  rib  as  a  valuable  sign.  The  apex  is  displaced  outward,  and 
the  area  of  impulse  is  increased.  The  increase  in  area  of  impulse  is  due 
to  the  hypertrophy  which  always  attends  adhesion  of  the  pericardium 
when  it  is  universal.  After  the  systole  there  is  frequently  felt  a  quick 
rebound  known  as  the  diastolic  shock,  which  is  said  to  be  characteristic 
of  pericardial  adhesions. 

In  pericardial  adhesions  Friedreieh'.s  sign,  collapse  of  the  cervical 
veins,  is  seen.  The  collapse  of  the  cervical  veins  takes  place  during  the 
diastole  of  the  heart.  We  may  also  see  inspiratory  swelling.  (Kuss- 
maul.)  In  addition  the  pulsus  paradoxus  is  significant  of  the  presence 
of  pericardial  adhesions,  or  rather  of  the  dilatation  that  succeeds  the 
adhesions.  The  pulse  is  small  and  feeble'during  inspiration,  assuming 
greater  strength  during  the  period  of  expiration. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     421 

Percussion.  The  area  of  cardiac  dulness  is  increased  usually  up- 
ward, extending  as  high  as  the  first  interspace.  The  area  of  dulness 
is  frequently  not  modified  by  respiration  ;  that  is,  it  is  not  lessened 
when  the  patient  takes  a  full  breath  and  the  lungs  expand  over  the 
precordial  region.  This  is  particularly  the  case  when  there  is  pleuritis 
associated  with  pericarditis,  a  common  association  in  the  large  majority 
of  cases. 

Auscultation.  On  auscultation  the  signs  vary.  The  sounds  are  due 
to  hypertrophy  or  to  dilatation;  and  it  must  not  be  forgotten  that  they 
frequently  arise  on  account  of  pericardial  adhesions.  In  the  former 
condition  the  first  and  second  sounds  are  accentuated  ;  in  the  latter,  a 
murmur  may  be  heard  at  the  apex,  loud  and  systolic  in  time. 

In  pericardial  adhesions  the  physical  signs  depend  upon  the  con- 
dition of  the  heart-muscle  at  the  time  of  the  examination.  At  first 
we  have  the  physical  signs  of  hypertrophy  with  retraction  of  the 
interspaces,  particularly  at  the  apex,  or  the  space  at  the  xiphoid 
cartilage.  This  is  particularly  the  case  in  young  subjects.  In  the 
later  period  of  the  disease  the  physical  signs  of  dilatation  arise,  indi- 
cated by  increase  in  transverse  dulness,  enfeeblement  of  impulse  and 
of  sounds,  with  the  development  of  a  murmur  at  the  apex,  undula- 
tion of  the  veins  in  the  neck,  and  the  pulsus  paradoxus.  The 
physical  signs  of  associate  pleurisy  aid  in  the  recognition  of  adherent 
pericardium.  Diminution  of  the  breath -sounds,  increase  in  the  area 
of  cardiac  dulness,  lessened  fremitus  in  the  neighborhood  of  the  heart 
pointing  to  pleural  thickening,  are  associate  evidence.  Sansom  con- 
siders the  presence  of  pulmonary  tuberculosis  of  value,  as  pointing 
to  the  occurrence  of  pericardial  adhesions,  for  the  associate  pleural 
adhesions  are  likely  to  be  attended  by  tuberculous  pericarditis. 

I  have  learned  to  suspect  adhesive  pericarditis  in  a  young  subject 
the  victim  of  valvulitis,  when  the  symptoms  do  not  yield  to  treatment. 
In  short,  when  the  heart  is  not  affected  by  digitalis.  Unfortunately, 
the  physical  signs  are  often  not  conclusive. 

The  subjective  symptoms  of  adherent  pericardium  are  those  of  dila- 
tation or  hypertrophy  of  the  heart,  whichever  one  of  the  two  is  in 
excess. 

Indurative  mediastino-pericarditis  with  adhesion  may  occur  with  or 
without  tibrous  inflammation  and  and  adhesion  of  the  structures  in  the 
anterior  mediastinum.  The  pericardium  is  adherent  and  thickened. 
Rarely  the  anterior  mediastinum  alone  is  a  mass  of  fibrous  inflamma- 
tion. Peritonitis  and  perihepatitis  may  be  found.  The  entire  process 
may  be  tuberculous.  The  symptoms  are  dyspnoea,  venous  engorgement, 
cyanosis,  enlargement  of  the  liver,  ascites,  and  dropsy.  The  j>/nisi<-<i/ 
signs  arc  those  of  extreme  cardiac  dilatation,  the  pulsus  paradoxus, 
collapsing  jugular  veins  during  diastole,  due  to  the  dragging  upon  the 
innominate  veins  and  cava  by  the  fibrous  adhesions,  or  to  stretching 
and  narrowing  of  the  aortic  arch  by  these  adhesions,  or  inspiratory 
swelling  of  the  veins  of  the  neck.  A  friction-sound,  systolic  in  time, 
heard  over  the  sternum,  increased  when  the  arm  is  held  up — medias- 
tinal friction,  so  called,  has  been  described  in  this  affection. 

It  usually  follows  an  acute  chest-affection,  occurs  most  frequently 


422    '  SPECIAL  DIAGNOSIS. 

in  young  adults,  and  in  males.  It  should  also  always  be  suspected  in 
cases  of  dilatation  and  valvulitis  in  which  compensation  does  not  take 
place,  notwithstanding  the  best  treatment. 

Endocarditis. 

Endocarditis  may  be  acute  or  chronic.  In  either  form  it  is  usually 
secondary.  The  acute  form  is  divided  into  simple  and  so-called  malig- 
nant or  mycotic  endocarditis. 

Simple  Endocarditis.  Acute  endocarditis  rarely  occurs-  pri- 
marily. It  usually  occurs  secondarily  to  general  morbid  processes. 
The  pathological  antecedents  are  acute  rheumatism,  tonsillitis,  whoop- 
ing-cough, scarlet  fever,,  gonorrhoea,  rarely  smallpox  and  typhoid  fever. 
It  is  of  common  occurrence  in  pneumonia  and  tuberculosis.  It  is  fre- 
quent in  chorea.  In  the  simple  form  it  occurs  in  septic  inflammations 
and  in  debilitating  diseases,  as  cancer.  It  may  occur  in  gout  and 
develop  in  the  course  of  Bright' s  disease. 

Symptoms.  The  symptoms  of  simple  endocarditis  are  scarcely  ob- 
served during  the  early  course  of  the  disease.  The  process  is  latent, 
and  there  are  no  indications  of  cardiac  disease.  The  physical  signs 
alone  betray  its  presence.  Unless  these  are  sought  for  the  disease  is 
overlooked.  The  subjective  symptoms  are  negative.  In  the  course  of 
rheumatism  or  chorea,  or  during  convalescence  from  the  former,  the 
patient  may  complain  of  palpitation,  and  increased  frequency  and 
irregularity  of  the  heart  may  be  observed.  At  the  same  time  there 
may  be  a  rise  in  temperature,  not  attended  by  any  increase  of  the 
rheumatic  symptoms,  which  should  call  attention  to  the  cardiac  com- 
plication. The  rise  is  not  marked,  and  may  not  assert  itself  during 
the  severity  of  the  disease. 

Physical  Signs.  On  examination  a  murmur  is  detected  in  one  of 
the  cardiac  areas.  The  murmur  is  soft,  low  in  pitch,  and  follows  the 
laws  of  transmission,  according  to  its  situation.  Instead  of  a  distinct 
murmur  a  roughening  of  the  first  sound  alone  may  be  heard.  Pre- 
ceding the  murmur  the  heart's  action  may  be  quickened  and  arhyth- 
mical  ;  the  first  sound  may  change  in  character  from  day  to  day  or  be 
accentuated  ;  the  second  reduplicated  at  the  apex  and  accentuated. 
The  new  sounds  may  disappear  at  first  when  the  patient  sits  up ; 
later  they  persist.  The  murmur  must  not  be  mistaken  for  the  mur- 
mur at  the  apex  in  cardiac  dilatation,  or  the  murmur  which  may  be 
heard  in  the  course  of  fevers,  or  the  murmur  of  anaemia,  which  may 
rapidly  develop  in  rheumatism  and  other  affections. 

Malignant  Endocarditis.  Unlike  simple  endocarditis,  the  ma- 
lignant form  very  rarely  develops  in  the  course  of  rheumatism  and 
chorea.  It  occurs  more  frequently  in  .pneumonia  than  in  any  other 
disease.  It  arises  in  the  course  of  erysipelas,  septicaemia,  puerperal 
fever,  and  gonorrhoea.  It  may  occur  in  the  course  of  dysentery.  It 
is  usually  a  streptococcus  infection. 

The  Symptoms.  The  symptoms  are  (1)  those  due  to  the  morbid  pro- 
cess— the  local  infectious  inflammation  ;  (2)  the  physical  signs  ;  (3) 
those  due  to  emboli.     The  general  symptoms  due  to  the  morbid  specific 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM. .   423 

process  are  septic  in  nature.  The  febrile  phenomena  may  be  one  of 
four  groups:  (1)  The  fever  is  paroxysmal.  Chills  and  fever  occur 
daily  or  at  intervals  of  two  or  three  days,  resembling  types  of  ma- 
larial fever.  Each  paroxysm  is  attended  by  profuse  sweats.  Rapid 
exhaustion  ensues.  The  fever,  instead  of  being  distinctly  intermittent, 
may  be  irregularly  intermittent.  (2)  The  fever  is  excessive  and  con- 
tinued, and  a  typhoid  state  frequently  sets  in.  The  temperature  is 
irregular  ;  extreme  prostration,  low  delirium,  sordes,  subsultus,  and 
other  symptoms  of  that  state  arise.  (3)  The  fever  is  moderate  and 
continued.  Physical  examination,  however,  reveals  the  presence  of 
marked  endocarditis.  In  this  group  chronic  heart  disease  has  usually 
preceded  the  affection.  The  duration  may  be  prolonged.  (4)  The  fever 
may  be  remittent.  Petechial  rashes  and  erythema  are  common,  so  that, 
as  pointed  out  by  Osier,  the  disease  may  resemble  the  eruptive  fevers. 
The  sweating  is  profuse,  contributing  to  the  profound  exhaustion  which 
usually  ensues.  A  septic  diarrhoea  occurs.  In  a  few  rapidly  fatal  cases 
jaundice  has  occurred.  Again,  the  symptoms  may  be  almost  exclu- 
sively cerebral,  resembling  cerebro  spiual  or  basilar  meningitis. 

The  embolic 'phenomena  are  due  to  escape  into  the  blood-current  of 
soft  vegetations  from  the  valves  of  the  left  heart  (for  the  right  heart  is 
rarely  affected),  which  are  carried  by  the  blood- stream  into  distant 
points  of  the  circulation.  Emboli  occur  in  the  brain,  producing  aphasia 
or  hemiplegia;  they  occur  in  the  retina,  causing  some  complaint  as  to 
vision,  but  are  accurately  recognized  by  ophthalmoscopic  examination. 
They  occur  in  the  kidneys,  producing  bloody  urine  and  renal  pain.  In 
nearly  all  cases  the  spleen  is  the  seat  of  embolism,  and  in  some  instances 
infarctions  may  take  place  in  this  organ  alone.  The  spleen  is  always 
enlarged,  and  the  infarct  may  cause  pain  and  increased  tenderness  on 
pressure.  Emboli  in  the  skin  and  mucous  membranes  present  the 
most  striking  phenomena.  The  hemorrhages  underneath  the  skin 
are  minute.  They  are  seen  in  the  extremities,  but  may  also  be  found 
in  the  trunk.  They  occur  in  the  mucous  membranes,  as  those  of 
the  mouth  and  tongue.  They  are  seen  in  the  bulbar  conjunctivae,  and 
in  the  conjunctivae  of  the  lids. 

Physical  Signs.  Repeated  examinations  are  necessary  in  some  cases 
to  determine  the  presence  of  a  murmur,  or  to  decide  whether  a 
previously  existing  organic  lesion  is  the  seat  of  an  acute  process. 
Variations  in  the  character  of  the  murmur  from  day  to  day  are  char- 
acteristic of  malignant  endocarditis.  In  organic  heart  disease  with 
dilatation  and  failure  of  compensation,  irregular  fever  followed  by 
embolic  phenomena  points  to  the  occurrence  of  an  infectious  process 
on  the  antecedent  valvulitis. 

Diagnosis.  When  embolic  phenomena  are  present  the  diagnosis 
is  made  without  much  difficulty.  The  more  pronounced  general 
symptoms  distinguish  it  from  simple  endocarditis.  The  tempera- 
ture-range, the  septic  and  typhoid  symptoms,  belong  to  the  malig- 
nant form.  The  more  prolonged  cases  with  moderately  continuous 
fever,  without  apparent  primary  cause,  are  frequently  confounded  with 
typhoid  fever.  This  is  readily  appreciated  when  the  symptoms  of  the 
two  are  compared.     In  both  there  is  fever  of  a  continued  type,  with 


424  SPECIAL  DIAGNOSIS. 

the  symptoms  of  the  typhoid  state,  including  delirium.  In  both  there 
are  enlargement  of  the  spleen,  diarrhoea,  and  abdominal  tenderness. 
In  both  there  may  be  infarctions,  although  they  are  extremely  rare  in 
typhoid  fever,  and  only  occur  late  in  the  disease.  In  both  there  is 
progressive  exhaustion.  In  endocarditis  the  onset  may  be  more  abrupt. 
The  fever  does  not  present  the  regularity  of  type  that  is  seen  in  the 
development  of  typhoid.  In  endocarditis  there  is  more  oppression 
and  dyspnoea  early  in  the  course  of  the  disease  than  in  typhoid  fever. 
In  endocarditis  the  source  of  the  infection  may  be  discovered,  as  in 
the  genito-urinary  organs,  the  lungs,  the  bones,  etc.  The  diazo-reac- 
tion  is  found  in  typhoid  fever  after  the  fifth  day,  but  rarely,  if  ever, 
in  endocarditis.  The  results  of  bacteriological  examination  distinguish 
the  two  affections.  This  ought  to  be  of  value  in  endocarditis,  because 
the  process  is  usually  due  to  a  staphylococcus  or  streptococcus  infec- 
tion ;  either  micro-organism  may  be  found  in  any  suppurations  which 
may  possibly  be  present.  In  a  child  recently  seen  by  me  in  the  relapse 
of  an  attack  of  typhoid  fever,  malignant  endocarditis  was  thought  to 
be  present,  because  of  a  loud  and  rough  murmur  at  the  pulmonary 
orifice.  Fortunately  the  murmur  was  present  in  the  apyretic  period, 
and  as  the  child  was  anaemic  its  exaggeration  was  pronounced  to  be 
due  to  the  fever. 

Malignant  endocarditis  must  be  distinguished  from  cerebrospinal 
fever,  and  from  smallpox  of  a  hemorrhagic  type.  We  must  rely  oh 
the  local  cardiac  symptoms  and  physical  signs,  and  the  preponderance 
of  these  over  the  other  symptoms.  Of  course,  the  prevalence  of  an 
epidemic  and  a  history  of  exposure  are  of  service  in  the  distinction 
between  the  diseases  Examination  of  the  blood  excludes  the  forms  of 
malaria  which  formerly  were  mistaken  for  endocarditis. 

Chronic  Endocarditis.  Chronic  endocarditis  may  follow  the 
acute  form  or  develop  in  the  course  of  atheroma  or  of  endarteritis  due 
to  alcoholism,  the  poison  of  syphilis  or  of  gout.  If  associated  with 
endarteritis,  the  endocardial  change  may  be  part  of  the  general  degen- 
erative changes  which  occur  in  the  aging  process.  It  may  be  of 
dynamic  origin,  often  following  prolonged  heavy  muscular  exertion, 
by  which  the  valves,  particularly  at  the  aortic  orifice,  have  been  sub- 
jected to  a  strain.  The  process  is  slow  and  insidious,  and  leads  to  the 
changes  in  the  valve-segments  which  constitute  chronic  valvular  disease. 

Symptoms.  The  symptoms  of  chronic,  or  sclerotic,  endocarditis  are 
the  symptoms  of  chronic  valvular  disease.  Insufficiency  or  obstruction, 
or  both  combined,  take  place  at  the  affected  valve- orifice.  The  outflow 
of  blood  is  retarded  in  obstruction.  Backward  flow,  or  regurgitation, 
takes  place  in  insufficiency  in  the  opposite  direction  from  the"  normal 
blood- current.  When  there  is  obstruction  hypertrophy  usually  develops 
to  meet  it.  If  the  obstruction  is  moderate,  and  the  person  remains  in 
good  health,  the  hypertrophy  is  sufficient  to  overcome  the  obstruction. 
In  this  manner  the  effect  of  the  valve  lesion  is  compensated  for.  On  the 
other  hand,  when  blood  is  permitted  to  flow  by  regurgitation  backward 
into  the  cavity — that  is,  in  the  opposite  direction  to  its  usual  course — it 
meets  a  blood-current  flowing  to  this  cavity  in  the  normal  direction, 
and  the  result  is  overdistension,  or  overfilling,  of  the  cavity.      Dilata- 


DISEASES  OF  HEART,  BLOOD  VESSELS,  AND  MEDIASTINUM.     425 

tion  ensues,  and  may  persist.  If  the  regurgitation  takes  place  sud- 
denly, the  dilatation  continues;  if  gradually,  as  in  chronic  endocarditis, 
the  dilatation  is  attended  with  hypertrophy.  Thus,  when  there  is 
regurgitation  from  the  left  ventricle  into  the  left  auricle,  on  account  of 
incompetency  at  the  mitral  orifice,  the  auricle  becomes  overdistended 
with  blood,  for  it  is  filling  with  blood  from  the  pulmonary  veins  at 
the  same  time.  This  overdistention  can  only  be  overcome  by  some 
hypertrophy.  When  this  is  not  sufficient  the  blood  is  forced  back  into 
the  pulmonary  circulation,  with  the  consequences  hereafter  to  be  men- 
tioned. 

The  symptoms  of  chroniG  endocarditis  are  latent  if  the  lesions  are 
compensated  for;  if  not,  symptoms  of  failure  in  compensation  occur  or 
dilatation  of  the  heart  arises.  The  physical  signs  are  those  of  chronic 
valvulitis.  The  character  of  the  signs  depends  upon  the  lesion  of  the 
affected  valve. 

Disease  of  the  Coronary  Arteries. 

Atheroma,  which  may  be  associated  with  the  process  in  other 
vessels,  or  distinctly  localized  to  the  coronary  arteries  affects  these 
vessels.  Its  causal  factors  are  those  of  endarteritis  elsewhere.  Its 
influence  on  the  nutrition  of  the  heart,  either  by  sudden  obstruction 
of  the  vessels  by  an  embolus,  or  by  their  gradual  closure,  is  appar- 
ent. If  an  atheromatous  coronary  artery  is  suddenly  obstructed  by 
an  embolus,  death  may  be  immediate.  This  is  a  common  cause  of 
sudden  death  to  bear  in  mind.  In  other  instances  thrombosis  may 
take  place,  followed  by  ansemic  infarction,  myocarditis,  and  mural 
aneurism.  In  this  class  of  cases  the  onset  of  the  symptoms  may  be 
sudden.  Precordial  oppression  or  angina  pectoris  may  be  the  first 
indication.  Succeeding  this,  dyspnoea,  dilatation  of  the  heart,  and 
venous  stasis  occur.  The  presence  of  an  aneurism  may  be  made  out. 
The  heart's  action  is  persistently  rapid  and  may  be  arhythmical.  If 
there  has  not  been  previous  valvulitis,  no  murmurs  are  heard  until 
dilatation  ensues.  The  patient  may  live  three  or  four  weeks,  or  as 
many  months. 

In  a  third  group  of  cases  occlusion,  either  from  the  endarteritis  or 
from  a  slowly  forming  thrombus,-  is  so  gradual  as  i0  ]eac|  f0  mvo_ 
carditis  only  with  the  attending  symptoms. 

Diagnosis.  Unfortunately,  too  often  the  diagnosis"  can  only  be 
provisional.  Sudden  death  may  be  attributed  to  coronary  artery  dis- 
ease if  there  has  been  a  history  of  previous  attacks  of  angina,  if  there 
is  evidence  of  arterial  disease  elsewhere,  and  if  dyspnoea  or  anginoid 
symptoms  preceded  the  fatal  termination.  Atheroma  and  thrombosis 
may  be  suspected  if  a  patient,  in  whom  there  is  no  valvular  disease, 
pulmonary  or  renal  disease  to  account  for  it,  is  seized  with  angina 
pectoris  or  dyspnoea  ;  providing  tachycardia  and  arhythmia  follow, 
and  in  a  short  time  cardiac  dilatation,  venous  stasis,  etc.  In  a  male, 
aged  forty-three  years,  without  syphilis,  but  with  a  history  of  ante- 
cedent rheumatism,  an  attack  of  angina  pectoris  followed  some  unusual 
exertion.      Prior  he  had  been  in  the  most  perfect  health.     The  attack 


426  SPECIAL  DIAGNOSIS. 

was  followed  by  dyspnoea  and  remarkably  rapid  heart-action  without 
cause.  The  physical  signs  of  acute  congestion  of  the  lower  lobe  of 
the  right  lung  followed  within  twenty-fours  of  the  attack  of  angina. 
The  patient  was  ill  three  months.  He  improved  somewhat,  but  rapidity 
of  the  heart's  action  and  some  stasis  in  the  lung  persisted.  Gradually 
cardiac  dilatation  ensued  with  a  murmur  in  the  tricuspid  area.  Death 
took  place  from  pulmonary  congestion.  At  the  autopsy  the  coronary 
arteries  were  atheromatous  ;  the  left  was  filled  with  an  old  thrombus ; 
there  were  extensive  myocarditis  and  an  aueurism  of  the  left  ventricle. 

In  another  case,  male,  aged  seventy-two  years,  with  general  atheroma 
but  no  valvulitis,  sudden  precordial  distress,  tachycardia,  and  per- 
sistent dyspnoea  were  followed  by  cardiac  dilatation,  mitral  incompe- 
tency, general  anasarca. 

I  have  said  elsewhere,  a  persistently  rapid  pulse,  uninfluenced  by 
digitalis,  indicates  pericardial  adhesion  in  the  young ;  the  same  pulse 
influenced  by  treatment  points  to  coronary  artery  disease  in  the  middle- 
aged  and  senile. 

Myocarditis. 

Myocarditis  may  be  acute  or  chronic.  General  myocarditis  is  always 
acute.  The  local  form  may  be  acute  or  chronic,  depending  upon  the 
degree  of  the  primary  cause.  The  entire  muscle  or  only  a  portion  may 
be  affected.  The  local  variety  is  usually  due  to  a  thrombus  in  the  ter- 
minal endings  of  the  coronary  artery,  which  cuts  off  the  blood-supply. 
The  changes  are  those  of  myocarditis,  to  which  may  be  added  necrosis 
of  small  areas  and  the  development  of  aneurism.  JEtiology.  Path- 
ological antecedents  of  acute  general  myocarditis  are  the  fevers,  partic- 
ularly typhoid  and  typhus  fever,  pneumonia,  diphtheria,  and  septic 
fevers  generally.  Chronic  myocarditis  is  usually  associated  with  ath- 
eroma, one  of  the  causes  of  which  occurs  in  the  later  stages  of  Bright' s 
disease,  (see  Atheroma).  The  result  of  myocarditis,  when  acute,  is 
dilatation  of  the  heart,  fatty  heart,  or  aneurism  of  the  heart.  Chronic 
myocarditis  is  followed  by  fatty  heart,  by  dilatation,  by  the  so-called 
fibroid  heart  or  fibrous  myocarditis,  and  by  aneurism.  The  above  facts 
in  aetiology  are  important  in  diagnosis. 

Symptoms.  The  symptoms  of  acute  myocarditis  are  vague.  In 
the  course  of  one  of  the  above-mentioned  diseases  the  patient  may 
complain  of  some  oppression  in  the  prsecordia  and  suffer  from  dysp- 
noea ;  attacks  of  syncope  may  occur,  and  sighing  may  be  frequent. 
The  pulse  becomes  more  rapid  and  weak,  but  is  usually  not  irregular. 
The  circulation  is  much  depressed,  the  hands  may- be  cold,  the  face 
pallid.  These  symptoms  may  be  accounted  for  by  the  extreme  exhaus- 
tion that  follows  fever,  although  there  is  no  doubt  that  some  myocar- 
ditis exists  in  all  cases,  particularly  if  there  is  high  temperature  in 
the  course  of  the  fever.  In  many  cases  the  patient  does  not  com- 
plain of  any  symptoms  referable  to  the  heart,  death  taking  place 
suddenly,  either  in  the  course  of  the  disease  or  after  it  has  spent  its 
force,  from  acute  dilatation  or  cardiac  paralysis.  This  is  particularly 
the  case  in  pneumonia  and  diphtheria.  In  the  latter  affection  the 
sudden  appearance  of  cardiac  symptoms,  dyspnoea,  cyanosis,  and  cold 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     4^7 

extremities  may  be  due  to  paralysis  of  the  heart.  Physical  Signs. 
Enfeeblement  of  the  heart-sounds,  sometimes  with  increased  accentua- 
tion of  the  mitral  first  sound,  is  observed.  The  impulse  and  apex- 
beat  are  scarcely  perceptible,  or  absent  altogether.  If  acute  dilatation 
supervenes,  the  area  of  duluess  may  be  increased. 

The  symptoms  of  chronic  myocarditis  are  obscure  and  indefinite,  and 
in  the  majority  of  cases  depend  upon  the  secondary  changes  that  have 
taken  place  in  the  heart  muscle.  If  there  is  atrophy  of  the  fibroid 
heart,  the  pulse  is  feeble,  slow,  and  irregular.  It  may  be  as  slow  as 
thirty  or  forty  beats  to  the  minute.  Irregularity  is  not  necessarily 
present,  but  intermittency  is  of  frequent  occurrence.  The  patient 
complains  of  dyspnoea  aggravated  by  exertion.  Attacks  of  angina 
pectoris  are  likely  to  occur.  The  symptoms  of  dilatation  of  the  heart 
may  ensue  later,  with  oedema,  cyanosis,  and  congestions.  In  fatty 
degeneration  of  the  heart  the  pulse  is  increased  in  frequency ;  there  are 
cardiac  irregularity,  palpitation,  and  dyspnoea.  These,  however,  are 
also  the  symptoms  of  dilatation,  which  usually  succeeds  the  degenera- 
tion. The  heart-sounds  are  weak.  If  dilatation  has  set  in,  a  mur- 
mur is  heard  at  the  apex,  with  galloping  rhythm  of  the  heart.  In 
fatty  degeneration  attacks  of  collapse  with  slow  pulse  are  common. 
Shortness  of  breath  on  exertion  may  occur.  Cardiac  asthma  occurs 
at  night,  and  sighing  and  yawning  are  of  frequent  occurrence  during 
the  day.  The  patient  usually  sleeps  badly.  The  cerebral  functions 
are  more  or  less  in  abeyance,  the  action  of  the  mind  is  sluggish;  the 
patient  may  have  delusions  or  become  maniacal.  Cheyne- Stokes 
breathing  was  formerly  thought  to  be  of  diagnostic  significance. 

Chronic  myocarditis  must  be  distinguished  from  fatty  overgrowth 
of  the  heart.  This  cardiac  change  is  frequently  seen  in  brewers  and 
saloon-keepers,  and  is  usually  associated  with  obesity.  The  pulse  may 
be  feeble,  the  heart-sounds  weak  and  muffled.  The  patients  are  sub- 
ject to  attacks  of  asthma,  and  frequently  have  bronchitis  and  emphy- 
sema. Vertigo  is  of  common  occurrence.  Death  may  occur  during 
syncope. 

Aneurism  of  the  Heart. 

Aneurism  of  the  valves,  following  endocarditis,  cannot  be  recognized 
during  life.  Aneurism  of  the  walls  usually  results  from  chronic  myo- 
carditis. The  aneurism  develops  at  the  apex  in  the  left  ventricle. 
The  symptoms  are  indefinite.  In  rare  cases  a  marked  bulging  has  been 
noted  in  the  region  of  the  apex,  and  the  tumor  may  perforate  the 
chest-wall.  A  projection  beyond  the  normal  line  of  cardiac  dulness 
may  be  detected  by  stethoscopic  or  plessimctric  percussion.  The  symp- 
toms arc  those  of  myocarditis  and  of  dilatation  of  the  heart. 

Rupture  of  the  heart  is  one  of  the  causes  of  sudden  death,  often 
without  previous  symptoms.  The  accident  takes  place  during  exertion. 
Quain  collected  one  hundred  cases,  in  seventy-one  of  which  death  took 
place  without  previous  warning.  In  other  instances  there  was  a  seii>e 
of  anguish,  and  suffocation  in  the  cardiac  region.  The  physical  signs 
of  slowly  developing  pericardial  effusion  may  be  ascertained  if  the 
leakage  from  rupture  is  slow  in  progress. 


428  SPECIAL  DIAGNOSIS. 

Chronic  Valvular  Disease. 

Valvular  disease  includes  valvulitis  and  valvular  incompetency  ; 
there  is  either  obstruction  or  regurgitation  at  the  orifices  affected. 
Valvulitis  may  exist  with  or  without  symptoms  ;  valvular  incom- 
petency is  always  accompanied  by  symptoms.  Valvulitis  implies 
organic  disease  of  the  valves  ;  valvular  incompetency,  regurgitation 
through  orifices,  the  valves  of  which  cannot  close  it.  Valvulitis  may 
be  recognized  by  physical  signs  of  (1)  the  lesion,  (2)  the  secondary 
effects  of  the  lesion  on  the  heart  and  circulation — hypertrophy  or 
dilatation.  Valvular  incompetency  occurs  usually  in  dilatation, 
and  may  be  secondary  to  valvulitis.  It  is  recognized  by  both  signs 
and  symptoms.  Valvular  disease  is  without  symptoms  as  long  as  the 
heart-muscle  enlarges  sufficiently  to  keep  in  balance  the  impaired  circu- 
lation ;  compensation  is  then  said  to  be  complete.  When  compensation 
is  broken  we  then  have  the  subjective  symptoms  enumerated  above, 
all  in  consequence  of  dilatation  of  the  heart.  .  It  may  be  said  that 
valvulitis  is  of  no  significance  as  long  as  compensation  is  perfect.  To 
review — valvulitis  may  be  attended  by  physical  signs  in  the  heart  and 
vessels  only,  or  by  its  own  physical  signs,  the  physical  signs  of  dila- 
tation, and  the  symptoms  of  the  latter.  In  the  consideration  of  val- 
vular disease  it  is  more  profitable  to  take  up  the  symptoms  of  each 
valve-lesion,  bearing  in  mind  that  two  or  more  of  the  valves  may  be 
diseased  at  the  same  time,  or  that  both  obstruction  and  regurgitation 
may  be  present  at  the  same  time  at  the  same  valve-orifice. 

Aortic  Regurgitation,  Insufficiency  or  Incompetency. 
This  may  exist  for  a  long  time  without  presenting  any  symptoms. 
It  occurs  more  frequently  in  men  than  in  women,  and  is  more  common 
in  the  later  periods  of  life.  It  may  be  due  to  congenital  malformation, 
to  acute  endocarditis,  or,  as  is  most  frequently  the  case,  to  chronic 
endocarditis,  and  particularly  when  it  follows  strain  or  undue  exer- 
tion; alcoholism  and  syphilis  are  also  frequent  antecedents.  In  rare 
cases  it  follows  rupture  of  the  valves.  Relative  insufficiency  or  incom- 
petency is  of  very  rare  occurrence.  Insufficiency  is  frequently  combined 
with  obstruction. 

On  account  of  insufficiency,  or  regurgitation,  at  the  aortic  orifice  the 
blood  falls  directly  into  the  left  ventricle  during  the  diastole.  There 
is,  first,  a  relative  diminution  in  the  amount  of  blood  in  the  artery;  and, 
second,  an  increased  amount  of  blood  in  the  ventricle,  because  the  regur- 
gitated column  of  blood  meets  the  blood  from  the  auricle  which  is  filling 
the  chamber  at  the  same  time.  Dilatation  of  the  left  ventricle  ensues, 
and  is  followed  by  hypertrophy.  Dilated  hypertrophy  thus  arises.  The 
heart  becomes  enormously  enlarged.  This  is  one  of  the  conditions 
in  which  enormous  cardiac  enlargement  takes  place — -so-called  cor 
bovinum.  If  this  valve-lesion  occurs  at  the  period  of  life  and  from 
the  causes  above  mentioned,  it  is  attended  by  more  or  less  sclerosis  of 
the  arteries. 

The  Genera/  Symptoms.  They  may  be  entirely  absent  as  long  as 
perfect  compensation  exists.  This  is  particularly  the  case  if  there  is 
but  little  general  arterial  sclerosis.      Coincident  lesions  of  other  valves 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     429 

tend  to  break  the  compensation.  The  earlier  symptoms  are  those  due 
to  arterial  anaemia,  particularly  anaemia  of  the  brain.  They  are  head- 
ache, dizziness,  and  flashes  of  light  before  the  eyes.  The  patient  has 
an  anaemic  appearance,  and  soon  begins  to  suffer  from  shortness  of 
breath.  This  at  first  develops  upon  slight  exertion.  Palpitation  and 
oppression  about  the  chest  are  complained  of,  readily  excited  by  undue 
exertion.  Pain  is  a  common  symptom.  It  may  be  in  the  region  of 
the  prsecordia,  of  a  dull  aching  character,  and  radiate  to  the  neck  and 
down  the  arms,  particularly  on  the  left  side.  The  anginoid  pains  may 
be  followed  by  attacks  of  true  angina  pectoris.  The  latter  are  more 
common  in  aortic  regurgitation  than  in  any  other  valve-lesion. 

As  compensation  fails  venous  stasis  occurs  and  the  dyspnoea  increases. 
The  latter  is  worse  at  night  and  compels  the  patient  to  sleep  in  a  semi- 
erect  posture.  Congestion  of  the  lungs  takes  place,  giving  rise  to 
cough.  Hemorrhage  occurs,  but  not  so  frequently  as  in  mitral  disease. 
Oedema  of  the  feet  sets  in,  but  general  anasarca  is  not  common.  OEdema 
of  the  feet  may  be  due  to  the  attendant  anaemia. 

In  aortic  insufficiency  sudden  death  is  of  common  occurrence.  This 
may  take  place  at  night  during  an  attack  of  dyspnoea,,  or  occur  sud- 
denly upon  the  slightest  exertion,  such  as  straining  at  stool,  or  ascend- 
ing a  height,  or  walking  more  quickly  than  usual. 

The  Physical  Signs  of  Aortic  Regurgitation.  Inspection.  The  apex- 
beat  is  downward,  outward,  and  to  the  left.  It  may  be  as  low  as  the 
seventh  interspace,  and  as  far  out  as  the  anterior  axillary  line.  The 
area  of  cardiac  impulse  is  increased.  It  occupies  the  whole  praecordia, 
and  heaving  of  the  lower  half  of  the  chest  may  be  seen.  In  young 
subjects  there  is  praecordial  bulging. 

Palpation.  The  impulse  is  strong  and  heaving.  After  compensation 
fails  it  is  indefinite  and  wavy.  A  thrill,  diastolic  in  time,  may  be  felt 
if  the  hand  is  placed  about  the  middle  of  the  sternum. 

Percussion.  The  area  of  dulness  is  increased.  The  extent  is  greater 
than  that  in  any  other  valve-lesion,  and  the  enlargement  is  more 
particularly  downward,  and  to  the  left. 

Auscultation.  At  the  second  costal  cartilage  on  the  right  a  murmur  is 
heard,  diastolic  in  time.  This  may  be  its  seat  of  maximum  intensity. 
(See  Fig.  80.)  It  is  transmitted  along  the  coarse  of  the  sternum 
toward  the  apex.  In  some  instances  the  maximum  of  intensity  is 
greatest  at  the  fourth  left  costal  cartilage,  or  even  at  the  apex.  The 
second  sound  is  absent  in  the  large  majority  of  cases.  In  some  in- 
stances, however,  both  murmur  and  second  sound  may  be  heard  at  the 
same  time.  Other  murmurs  also  may  be  associated  with  aortic  regurgi- 
tation, not  always  due  to  disease  of  the  aortic  valves  : 

1.  A  systolic  murmur  at  the  second  costal  cartilage  on  the  right,  trans- 
mitted into  the  Vessels  of  the  neck,  short,  rough,  and  high  in  pitch.  It 
is  due  to  roughening  of  the  valve  segments,  or  to  atheroma  of  the  aorta. 

2.  A  murmur  at  the  apex,  rumbling  in  character,  localized  to  this 
area,  usually  presystolic  in  time.  It  is  the  murmur  described  by  Flint, 
who  attributes  it  to  flapping  of  the  mitral  segments,  which  during 
diastole  are  not  forced  back  against  the  heart-wall.  They  remain  in 
the  blood-current  and  produce  relative  narrowing. 


430  SPECIAL  DIAGNOSIS. 

3.  A  systolic  murmur  iu  the  mitral  area,  low  in  pitch,  clue  to  dila- 
tation.     This  occurs  when  failure  in  compensation  takes  place. 

Examination  of  the  Arteries.  Pulsation  of  the  peripheral  vessels  is 
more  common  iu  aortic  regurgitation  than  in  any  other  valve-lesion. 
The  carotids  throb,  the  temporals  pulsate,  the  brachial  and  radial  arte- 
ries are  conspicuous.  Pulsation  of  the  retinal  arteries  is  seen  with  the 
ophthalmoscope,  and  has  often  led  to  the  recognition  of  the  disease  by 
the  ophthalmologist  who  had  been  consulted  for  other  conditions.  The 
pulsation  is  of  a  jerking  character  ;  in  the  neck  it  may  simulate  the 
pulsation  of  an  aneurism.  The  aorta  can  be  seen  and  felt  at  the  supra- 
sternal notch.  The  abdominal  aorta  pulsates  vigorously  in  the  epigas- 
trium. On  auscultation  of  the  arteries  double  murmurs  may  be  heard 
in  the  carotids  and  subclavians,  and  in  rare  instances  they  are  present  in 
the  femorals  (see  Pulse). 

The  Capillary  Pulse.  This  is  seen  beneath  the  finger-nails,  or  on 
the  surface  of  the  skin,  as  the  forehead,  when  a  line  is  drawn  across  it. 
The  hyperemia  produced  on  either  side  of  the  line  becomes  alternately 
red  and  pale.  Capillary  pulse  also  occurs  in  anaemia,  and  at  times  in 
neurasthenia. 

The  Pulse.  The  pulse  is  significant  in  aortic  regurgitation.  The  so- 
called  water-hammer,  or  Corrigan's  pulse,  is  observed.  The  pulse  is 
quick  and  jerking,  and  after  striking  the  finger  immediately  recedes. 
It  is  most  marked  when  the  arm  is  held  up. 

Aortic  Obstruction.  Aortic  obstruction  occurs  in  the  aged,  and  with 
atheroma  of  the  arteries.  It  causes  some  diminution  in  the  amount  of 
blood  in  the  peripheral  circulation,  resulting  in  poor  nutrition  and  the 
development  of  ansemia. 

Symptoms.  Ansemia  develops  first,  and  embolic  phenomena  may  occur 
later.  The  symptoms  may  be  latent  until  the  occurrence  of  embo- 
lism. This  accident  is  not  uncommon  on  account  of  the  position  of 
the  aortic  valve.  The  emboli  are  distributed  throughout  the  arterial 
circuit,  and  may  lodge  in  the  brain,  kidneys,  or  spleen.  When  the 
obstruction  is  pronounced  the  blood-supply  in  the  arteries  is  diminished. 
Cerebral  ansemia  takes  place,  causing  dizziness  and  fainting.  Sleep 
is  more  disturbed  than  in  other  valve  affections,  because  of  the  cere- 
bral anseniia.  Palpitation  and  cardiac  pain  occur,  but  are  not  so  com- 
mon as  in  aortic  regurgitation.  When  compensation  fails,  dilatation 
of  the  left  ventricle  ensues,  followed  by  pulmonary  congestion  and 
stases  in  the  systemic  circulation. 

The  Physical  Signs.  There  is  hypertrophy  of  the  left  ventricle. 
Inspection.  The  apex-beat  is  displaced  downward  and  outward.  The 
impulse  is  strong  during  the  period  of  hypertrophy.  When  compen- 
sation fails  the  physical  signs  of  dilatation  ensue.  In  many  cases, 
from  the  very  first,  there  may  be  considerable  hypertrophy  without  the 
visible  impulse,  because  of  associate  emphysema,  which  is  cnmmon  to 
old  men  with  this  lesion. 

Palpation.  At  the  base  of  the  heart,  and  in  the  aortic  area,  a  thrill, 
systolic  in  time,  may  be  felt.  When  present,  it  is  usually  very  distinct, 
and  is  transmitted  along  the  course  of  the  vessels.  The  impulse  is  slow 
and  heaving,  if  hypertrophy  is  present ;  if  dilatation ,  feeble  and  indistinct. 


DISEASES  OF  HEAR  T,  BL  0  OB  VESSELS,  AND  MEDIA STIN  UM.     43 1 

Percussion.  The  area  of  dulness  is  increased,  in  the  earlier  stages^ 
to  the  left  and  downward.  After  compensation  is  broken,  dilatation 
with  increased  area  of  dulness  ensues. 

Auscultation.  A  murmur  is  heard  of  maximum  intensity  at  the 
second  costal  cartilage  to  the  right,  systolic  in  time,  and  transmitted 
in  the  course  of  the  bloodvessels.  (See  Fig.  79.)  It  is  usually  harsh 
and  loud,  but  may  be  musical.  As  the  heart  weakens,  the  intensity 
of  the  murmur  lessens  and  its  roughening  disappears.  It  becomes  soft 
and  low  in  pitch.  The  second  sound,  if  there  is  no  regurgitation,  is 
muffled  or  may  be  absent.  The  pulse  is  small  and  regular.  The 
tension  is  usually  increased.- 

Diagnosis.  A  systolic  murmur  at  the  aortic  orifice  may  be  due  to 
aortic  obstruction,  to  atheroma  or  dilatation  of  the  aorta,  ulcerative 
aortitis,  or  to  anaemia.  Huchard  describes  a  murmur  in  this  situa- 
tion, with  vibratory  thrill,  due  to  aberrant  chordae  tendineae.  The  mur- 
mur of  aortic  stenosis  is  distinguished  from  the  others  by  its  character, 
by  the  presence  of  thrill,  by  the  character  of  the  pulse,  and  by  its 
association  with  hypertrophy  of  the  left  ventricle.  A  murmur  due  to 
atheroma  of  the  aorta,  particularly  in  the  course  of  renal  disease,  is 
also  associated  with  hypertrophy  of  the  left  ventricle,  and  the  distinc- 
tion is  often  difficult  or  impossible.  The  slowness  of  the  pulse  is  more 
characteristic  of  aortic  obstruction.  The  murmur  of  anaemia  is  softer 
and  low  in  pitch.  There  is  no  thrill,  and  the  left  ventricle  is  not 
hypertrOphiecl.  Anaemic  murmurs  may  be  heard  elsewhere.  In 
atheroma  the  second  sound  is  usually  accentuated,  and  in  anaemia  it 
is  also  intensified. 

Mitral  Incompetency  or  Regurgitation.  The  regurgitation 
may  be  clue  to  disease  of  the  valves  from  previous  endocarditis,  which 
is  usually  of  rheumatic  origin,  or  to  inability  of  the  segments  to  close 
the  orifice  which  has  become  enlarged  as  part  of  the  dilatation  of  the 
cavities.  The  latter  occurs  in  dilatation  of  the  left  ventricle  under  all 
circumstances,  and  in  the  weakening  of  the  muscle  that  occurs  in  fevers 
and  in  anaemia.  It  is  thus  seen  that  the  murmur  of  mitral  insufficiency 
is  one  of  the  most  commonly  observed  of  all  valve-murmurs.  It  must 
not  be  forgotten  that  insufficiency  from  disease  of  the  valves  and  from 
disease  of  the  muscles  must,  if  possible,  be  distinguished  from  each 
other.  The  history  of  the  case  is' usually  essential  in  determining  the 
diagnosis. 

Disease  at  the  mitral  orifice  producing  insufficiency  has  more  serious 
effect  upon  the  pulmonic  and  arterial  circulation  than  disease  at  any  of 
the  other  orifices.  These  effects  must  be  understood  in  order  to  appre- 
ciate the  symptoms  of  mitral  incompetency.  They  are  as  follows:  1. 
With  each  systolic  contraction  the  blood  flows  back,  on  account  of  the 
insufficiency,  to  the  auricle,  where  it  soon  meets  a  volume  of  blood 
coming  from  the  lungs.  The  combined  volumes  of  blood  oven  list  cm  I 
the  auricle.  Dilatation  ensues,  and  because  of  increased  work  to  get 
rid  of  the  increased  contents,  hypertrophy  follows.  Dilated  hyper- 
trophy of  the  left  auricle  is  the  first  effect.  2.  As  a  result  of  the 
above,  a  larger  amount  of  blood  is  forced  from  the  left  auricle  into  the 
left  ventricle  ;  dilatation  and  subsequent  hypertrophy  of  this  chamber 


432  SPECIAL  DIAGNOSIS. 

also  follow,  to  remove  the  fluid  3.  On  account  of  the  overdistended 
auricle  the  pulmonary  veins  are  not  fully  emptied  during  the  diastole 
of  that  chamber.  The  veins  are  therefore  engorged  and  interfere  with 
the  flow  of  blood  through  the  pulmonary  circuit.  In  consequence  of  the 
backward  flow  of  blood  the  vessels  in  the  pulmonary  circuit  are  dilated 
and  overdistended  with  blood.  The  right  ventricle  is  compelled  to  act 
more  vigorously,  and  even  then  cannot  empty  itself  freely.  Dilatation 
and  hypertrophy  of  the  right  ventricle  ensue.  4.  This  causes  obstruc- 
tion of  the  flow  of  blood  from  the  right  auricle  to  the  right  ventricle; 
dilatation  and  hypertrophy  of  its  chambers  follow.  If  perfect  com- 
pensation ensues  through  hypertrophy  of  both  ventricles,  engorgement 
in  the  lungs  may  not  be  observed.  Moreover,  the  left  ventricle  is 
allowed  to  send  out  sufficient  blood  to  supply  the  wants  of  the  system. 
This  compensation  may  continue  for  years.  If  it  fails,  either  from 
increase  in  the  valve-lesion,  or  valvular  incompetency,  or  from  weaken- 
ing of  the  muscle,  a  normal  amount  of  blood  is  not  distributed  through- 
out the  aortic  area,  but  is  thrown  back  upon  (1)  the  left  auricle;  (2)  the 
pulmonary  circulation  ;  (3)  the  right  heart ;  and,  finally,  the  systemic 
veins.  For  a  time  the  pulmonary  circuit  will  alone  be  engorged,  sub- 
sequently the  systemic  veins  become  congested  because  of  dilatation  of 
the  right  auricle  and  incompetency  of  the  tricuspid  valves.  We  then 
have  the  secondary  effects  of  stases  upon  the  various  organs  of  the 
body,  with  cyanotic  induration  and  the  development  of  dropsies. 
Mitral  incompetency  without  disease  of  the  valves  is  of  frequent 
occurrence  in  emphysema  of  the  lungs  and  in  Bright' s  disease,  and 
is  a  condition  which  always  attends  hypertrophy  and  dilatation,  or 
may  take  place  from  various  causes  (see  Hypertrophy  and  Dilatation). 

Symptoms.  As  to  the  general  symptoms  :  In  a  large  number  of 
cases  perfect  compensation  may  continue  for  a  long  time.  No  subjec- 
tive symptoms  arise  nor  are  there  symptoms  due  to  dilatation.  If 
compensation  is  not  perfectly  effected  from  the  first,  or  is  broken  sud- 
denly or  gradually,  the  symptoms  of  dilatation  arise. 

In  patients  in  whom  compensation  remains  fairly  good  we  have  the 
characteristic  appearances  of  heart  disease.  It  is  to  this  class  of 
patients  that  the  general  descriptions. of  heart  disease  apply.  The  face 
is  pale  and  pinched,  the  lips  and  ears  dusky,  the  capillaries  of  the 
cheeks  enlarged,  the  finger-nails  clubbed,  particularly  in  children  ; 
shortness  of  breath  on  exertion  may  be  the  only  symptom  complained  of, 
and  this  may  exist  for  years.  The  patients  are,  however,  liable  to 
attacks  of  bronchitis  and  of  pulmonary  hemorrhage.  Palpitation  may 
occur  in  this  as  in  other  forms  of  heart  disease,  and  from  the  same  cause. 

When  the  compensation  is  broken,  symptoms  referable  to  the  heart 
and  to  engorgement  of  systemic  and  pulmonary  veins  occur.  Of  the 
former  palpitation  with  a  sense  of  oppression  is  the  most  common  ; 
pain  is  rare. 

Venous  engorgement  leads  to  congestions,  cyanosis,  and  dropsies. 
We  now  have  the  symptoms  of  dilated  right  heart  superadded.  The 
lungs  are  the  first  to  be  congested.  Dyspnoea  becomes  constant  and 
is  aggravated  by  exertion.  Cough  is  present,  excited  by  exertion  or 
speaking.      With  the  cough  there  is  bloody  expectoration.      Cyanosis 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     433 

occurs.  Congestion  of  other  organs  follows.  The  liver  is  enlarged  ; 
obstruction  in  the  portal  area  is  prominent;  chronic  gastritis  or  gastro- 
intestinal catarrh  ensues.  The  spleen  is  enlarged  ;.  ascites  develops, 
and  hemorrhoids  and  congestion  in  the  rest  of  the  portal  area  are  seen. 
The  kidneys  are  congested;  the  urine  is  scanty,  albuminous,  and  contains 
casts  and  blood-corpuscles.  At  the  same  time  that  the  internal  viscera 
are  congested  dropsies  take  place,  beginning  in  the  feet  and  extending 
to  the  rest  of  the  body.  Dropsy  may  have  been  present  in  the  feet  be- 
fore symptoms  of  portal  congestion  ensued. 

The  patient  may  be  relieved  and  compensation  continue  good  for  a 
long  time.  Frequent  attacks  of  dilatation  of  this  character  may  take 
place,  their  recurrence  being  due  to  lack  of  care  in  hygienic  matters, 
or  failure  in  health  from  other  cau-es.  Finally,  however,  the  compen- 
sation cannot  be  restored  ;  the  stases  persist ;  the  dropsies  become  more 
marked,  and  the  symptoms  of  chronic  cyanotic  induration  and  sec- 
ondary scleroses  of  the  internal  organs  follow.  It  must  not  be  forgotten 
that  this  is  the  chief  form  of  organic  heart  disease  seen  in  children. 

Physical  Signs.  On  inspection  the  precordial  area  appears  prom- 
inent; the  apex -beat  is  displaced  to  the  left  and  downward,  rarely  below 
the  sixth  interspace.  It  may  extend  to  the  anterior  axillary  line.  The 
cervical  veins  pulsate  and  are  distended.  The  area  of  impulse  is 
increased. 

Palpation.  The  character  of  the  impulse  depends  upon  the  stage  of 
the  disease  at  which  the  case  is  examined.  At  the  time  of  full  com- 
pensation it  is  strong  and  even.  When  this  is  broken,  it  is  feeble  and 
diffuse.     A  thrill  is  extremely  rare. 

Percussion.  The  area  of  dulness  is  increased  to  the  left.  The  trans- 
verse width  of  the  heart  is  much  increased  because  of  dilatation  of 
both  chambers.  The  area  extends  beyond  the  right  margin  of  the 
sternum  to  the  extent  of  an  inch  or  more  and  to  the  left  as  far  as  the 
mid-clavicular  line,  sometimes  to  the  anterior  axillary  line.  The  cardio- 
hepatic  triangle  is  preserved. 

Auscultation.  At  the  apex,  the  mitral  area,  a  murmur  is  heard.  The 
point  of  maximum  intensity  is  in  this  region.  It  is  systolic  in  time;  it 
may  replace  the  first  sound  entirely.  It  may  be  soft  and  low  in  pitch, 
or  rough,  high  in  pitch,  even  musical  in  character.  It  is  transmitted 
to  the  axilla  and  the  angle  of  the  scapula.  (See  Fig.  76. N»  In  some  in- 
stances it  may  be  heard  loudest  along  the  left  border  of  the  sternum. 
The  pulmonary  second  sound  is  accentuated;  the  accentuation  is  loudest 
in  the  pulmonary  area  at  the  second  left  interspace.  It  may  be  heard 
very  loud  over  the  right  ventricle,  between  the  parasternal  line  and 
the  left  edge  of  the  sternum.  The  murmur  of  mitral  insufficiency  is 
modified  by  the  position  of  the  patient  and  intensified  after  exertion. 
It  may  be  present  when  the  patient  is  lying  down,  and  disappear  in  an 
erect  posture.  It  may  disappear  when  the  patient  is  quiet  and  return 
after  exertion.      Other  murmurs  are  sometimes  heard  : 

1.  A  presystolic  murmur,  soft  or  rumbling.'  2.  When  dilatation 
ensuesa  low-pitched  systolic  murmur  is  heard  at  the  ensiform  cartilage 
and  at  the  lower  left  border  of  the  sternum.  It  is  due  to  tricuspid 
regurgitation. 

28 


434  SPECIAL  DIAGNOSIS. 

The  Bloodvessels.  The  amount  of  blood  in  the  arteries  is  diminished. 
There  is  notable  absence  of  visible  pulsation  in  the  arteries.  The  pulse 
at  first  is  full  and  regular.  It  is  notably  small  in  volume  and  soft. 
As  soon  as  failure  of  compensation  takes  place  the  pulse  becomes 
irregular.    The  irregularity  may  be  that  of  time  as  well  as  of  volume. 

Of  special  diagnostic  significance  are  :  the  position  of  the  murmur 
and  the  direction  of  its  transmission  ;  accentuation  of  the  pulmonary 
second  sound  ;  enlargement  of  the  transverse  diameter  of  the  heart, 
due  to  dilatation  of  both  ventricles. 

Diagnosis.  This  is  usually  easy  if  the  physical  signs  are  sought  for. 
Very  often  examination  of  the  heart  is  neglected,  and  the  patient  is 
treated  for  the  symptoms  that  arise  from  congestion  of  the  viscera. 
We  have  often  seen  chronic  gastritis  or  gastro-intestinal  catarrh,  due 
to  mitral  insufficiency,  not  relieved  because  the  primary  lesions  had 
not  been  ascertained.  In  the  same  way  cardiac  cough  or  dyspnoea  may 
be  overlooked.  It  is  important  in  the  diagnosis  to  determine,  if  possi- 
ble, the  nature  of  the  insufficiency,  whether  it  is  due  to  disease  or 
incompetency  of  the  valves.  As  previously  mentioned,  the  history  is 
possibly  the  only  means  by  which  a  diagnosis  can  be  made.  If  a  mitral 
murmur  ensues  in  old  people,  in  whom  there  has  been  physical  cause 
for  the  development  of  dilatation  and  hypertrophy,  as  in  emphysema 
or  arterio-sclerosis,  it  is  usually  due  to  incompetency  of  the  valve-leaf- 
lets to  close  the  orifice.  It  must  not  be  forgotten  that  the  mitral  area 
is  the  seat  of  a  number  of  murmurs  due  to  various  causes  (see  Auscul- 
tation). 

Mitral  Stenosis.  Obstruction  to  the  flow  of  blood  from  the 
auricle  to  the  ventricle  is  the  result  of  endocarditis,  and  particularly 
the  endocarditis  of  early  life.  It  is  of  much  more  frequent  occurrence 
in  women,  in  contradistinction  to  aortic  disease.  As  intimated,  it  is 
much  more  frequent  in  young  adults  and  children,  because  its  setiolog- 
ical  factors,  rheumatism  and  chorea,  are  then  more  prevalent. 

On  account  of  the  obstruction  of  the  orifice  changes  ensue  in  the 
auricle.  These  changes  depend  in  a  measure  upon  the  nature  of  the 
lesion.  In  the  so-called  buttonhole  contraction  they  are  very  marked. 
The  orifice  may  be  so  obliterated  in  rare  cases  as  to  admit  only  a  small 
probe.  Dilatation  and  hypertrophy  of  the  left  auricle  ensue  if  the 
valve-changes  take  place  gradually.  The  walls  of  the  auricle  are  thick- 
ened to  three  or  four  times  their  natural  size.  On  account  of  the  dilata- 
tion of  this  auricle  the  outflow  from  the  pulmonary  veins  is  impeded, 
which  in  turn  obstructs  the  circulation  of  blood  through  the  lungs.  As 
a  consequence  dilatation  and  hypertrophy  of  the  right  ventricle  occur. 
As  a  result  of  this  we  have,  later  on,  the  occurrence  of  relative  incom- 
petency at  the  tricuspid  orifice,  with  engorgement  of  the  systemic  veins. 
The  left  ventricle  does  not  take  part  in  "any  changes.  It  retains  its  nor- 
mal size,  but  it  may  look  small  in  comparison  with  the  right  ventricle. 

Symptoms.  If  hypertrophy  of  the  right  ventricle  ensues,  the  com- 
pensation may  be  sufficient  to  prevent  the  occurrence  of  symptoms  for 
many  years.  The  disease  may  exist  for  a  number  of  years  without 
discomfort  to  the  patient.  Because  of  its  rheumatic  origin  a  fresh 
endocarditis  may  develop,   particularly  as  most  of    the  subjects  are 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     435 

young,  and  hence  may  cause  danger.  If  fresh  endocarditis  occurs, 
embolic  symptoms  are  likely  to  follow.  These  take  place  particularly 
in  the  brain,  causing  hemiplegia  or  aphasia.  When  failure  of  compen- 
sation takes  place  the  symptoms  described  in  mitral  incompetency  arise. 
They  are  the  symptoms  of  dilatation  of  the  heart,  and  may  recur  fre- 
quently during  a  long  period  of  years. 

Dropsy,  however,  is  not  so  common  as  in  mitral  regurgitation. 
Visceral  stases  are  common  when  compensation  fails,  and  in  many 
cases  we  find  enlargement  of  the  liver  continuing  for  over  a  long 
period.  Ascites  may  in  rare  cases  be  the  only  manifestation  of  mitral 
obstruction. 

The  Physical  Signs  of  Mitral  Obstruction  are  more  striking  and  more 
diagnostic  of  the  lesion  than  the  physical  sigus  of  any  other  form  of 
organic  heart  disease.  As  the  disease  develops  in  children  with  soft 
ribs  the  local  deformities  are  very  marked. 

Inspection.  For  the  same  reason  precordial  bulging  is  more  prom- 
inent. Because  the  right  ventricle  is  hypertrophied,  the  sternum  and 
the  fifth  and  sixth  costal  cartilages  protrude.  It  is  not  usually  displaced, 
certainly  not  beyond  the  mid-clavicular  line.  The  impulse  is  not 
marked  at  the  apex.  In  the  third  and  fourth  interspaces  a  visible 
impulse  is  seen  along  the  margin  of  the  sternum.  After  dilatation 
the  extent  of  impulse  diminishes  and  the  veins  of  the  neck  become 
engorged,  the  blood  regurgitating  into  them  during  the  systole. 

Palpation.  In  the  large  majority  of  cases  a  distinct  fremitus  or  thrill 
is  felt — more  marked  in  the  fourth  or  fifth  interspace,  inside  of  the 
nipple.  It  is  usually  localized  to  a  small  area,  is  increased  during 
expiration,  and  is  of  a  twisting,  grating,  or  grinding  character.  It  is 
made  up  of  a  series  of  small  shocks  increasing  in  intensity,  culminat- 
ing in  a  sudden,  sharp  shock,  which  occurs  at  the  time  of  the  impulse. 
The  thrill  is  pathognomonic  and  may  be  present  when  other  signs,  as 
the  murmur,  are  absent  or  indistinct.  The  cardiac  impulse  is  felt 
strongest  at  the  lower  margin  of  the  sternum  and  in  the  third  and 
fourth  interspaces,  in  some -cases  even  in  the  second.  It  is  due  to  an 
enlarged  and  dilated  right  ventricle. 

Percussion.  The  area  of  cardiac  dulness  is  increased  upward  and 
to  the  right  and  left  of  the  margin  of  the  sternum.  Sometimes  it 
extends  upward  as  high  as  the  second  rib  ;  this  increase  is  quite  char- 
acteristic. 

Auscultation.  At  the  apex,  or  just  inside  of  the  position  of  the  apex- 
beat,  a  murmur  is  heard,  its  point  of  maximum  intensity  distinctly 
localized  to  this  spot.  It  is  usually  not  transmitted.  (See  Fig.  77.) 
It  is  of  a  churning  and  grinding  character,  or  vibratory  and  purring. 
It  is  usually  high  in  pitch  and  rough.  It  occurs  synchronously  with 
the  thrill,  and  terminates  with  a  loud  shock  that  is  heard  simultaneously 
with  the  first  sound.  It  is,  therefore,  presystolic  in  time.  As  has 
been  said  of  the  thrill,  so  it  may  be  said  of  this  murmur,  that  it  is  the 
only  murmur  that  is  pathognomonic  of  a  special  lesion.  It  indicates 
narrowing  of  the  mitral  orifice.  The  only  exception,  in  which  the 
lesion  is  absent,  although  the  murmur  is  present,  is  found  in  the  class 
of  cases  described  by  Flint,  referred  to  in  the  section  on  aortic  regurgi- 


436  SPECIAL  DIAGNOSIS. 

tation.      The   first   sound   is   loud,    clear,    and   abrupt ;    it   may   be 
thumping. 

The  presystolic  murmur  may  occupy  the  entire  period  of  the  dias- 
tole, but  in  the  large  majority  of  cases  it  occurs  in  the  latter  half  only, 
during  which  the  auricular  systole  occurs.  In  some  instances  it  is 
heard  in  the  middle  of  the  diastole. 

Associate  Murmurs.  1.  At  the  same  time  a  systolic  murmur  may 
be  heard  at  the  apex,  soft,  and  low  in  pitch.  It  may  be  transmitted 
into  the  axilla.  It  is  usually  due  to  associate  mitral  regurgitation. 
2.  At  the  lower  portion  of  the  sternum  a  systolic  murmur  is  heard, 
due  to  dilatation  and  incompetency  at  the  tricuspid  orifice.  Murmurs 
in  the  aortic  region  are  not  usually  heard. 

The  second  sound  at  the  pulmonary  orifice  is  usually  accentuated.  It 
is  heard  in  the  second  and  third  interspaces  along  the  left  edge  of  the 
sternum  ;  it  may  be  heard  at  the  apex.  Reduplication  of  the  first 
sound  is  often  observed.  Reduplication  of  the  second  sound  is  very 
common.  After  compensation  is  broken  other  murmurs  may  be 
heard,  and  the  presystolic  murmur  changes  in  character.  It  may  dis- 
appear entirely  and  be  replaced  by  a  sharp  first  sound.  The  short, 
high-pitched  systolic  shock  may  continue,  although  the  audible  murmur 
disappears.  It  disappears  probably  because  the  left  auricle  has  become 
weakened.  The  tricuspid  murmur  continues  during  this  period.  The 
points  of  distinction  are  (1)  the  position  of  the  murmur;  (2)  its  restricted 
area;  (3)  its  peculiar  character  ;  (4)  the  systolic  shock  which  takes  the 
place  of  the  first  sound;  (5)  the  thrill;  (6)  the  impulse  and  increased 
area  of  dulness  upward;  (7)  accentuated  pulmonary  second  sound  ; 
(8)  reduplication  ;  (9)  the  absence  of  the  pulse  of  aortic  regurgitation 
and  of  hypertrophy  of  the  left  ventricle. 

Presystolic  murmur  not  due  to  valvulitis*.  A  presystolic  murmur 
without  mitral  obstruction  may  occur  in  aortic  regurgitation  and  in 
adherent  peri  can  Hum. 

The  pulse.  With  perfect  compensation  the  pulse  is  slow,  regular, 
and  firm,  although  small.  If  the  orifice  is  much  narrowed,  small, 
weak,  and  irregular  in  force  and  rhythm.  When  compensation  fails  and 
the  right  heart  is  dilated  the  pulse  becomes  rapid,  quick,  weak,  small 
in  size,  and  irregular  in  force  and  rhythm.  The  dilatation  may  be 
so  great  that  the  right  auricle  and  over-distended  veins  may  press 
upon  the  aorta  or  the  innominate  and  subclavian  arteries.  The  pulse 
on  that  side  will  be  lessened  in  volume.1 

Tricuspid  Regurgitation  or  Incompetency.  Structural  dis- 
ease at  the  tricuspid  orifice  is  of  comparatively  rare  occurrence.  In- 
sufficiency is  more  frequent,  and  is  due  to  dilatation,  with  relative 
insufficiency  of  the  valve-orifice.  It  occurs  secondarily  to  obstructive 
lung  diseases,  as  emphysema  and  cirrhosis,  and  is  secondary  to  regurgi- 
tation at  the  mitral  orifice,  which  leads  to  stases  in  the  lungs. 

The  Symptom*.  The  symptoms  were  detailed  in  speaking  of  the 
mitral  valve  affections.  They  are  those  of  obstruction  in  the  pulmo- 
nary circulation  and  engorgement  of  the  systemic  veins. 

1  Popoff :  British  Medical  Journal,  1893. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     437 

Inspection.  The  physical  signs  of  dilatation  of  the  right  heart  are  seen. 
An  impulse  in  the  epigastrium  is  noted.  This  is  seen  especially  between 
the  xiphoid  cartilage  and  the  left  margin  of  the  ribs.  Pulsation  to  the 
right  of  the  sternum  and  in  the  second  and  third  intercostal  spaces  may 
also  be  observed.  The  veins  of  the  neck  are  also  seen  to  pulsate.  In 
addition  to  the  wavy  pulsation,  regurgitation  of  the  blood  into  the  right 
auricle  causes  transmission  of  the  pulse-wave  into  the  veins.  The  pulsa- 
tion is  systolic  in  time.  It  is  more  marked  in  the  right  jugular  than  in 
the  left,  and  in  the  external  than  in  the  internal  veins.  With  the  pulsa- 
tion, regurgitation  is  readily  observed  by  emptying  the  external  vein. 
Place  the  finger  firmly  on  the  vein  just  above  the  clavicle,  move  it  along 
the  course  of  the  vein  in  the  direction  of  the  inferior  maxillary  bone. 
The  vein  is  thus  emptied  of  blood,  and  with  each  systole  of  the  heart 
it  will  be  seen  to  fill  up  from  below  in  rhythmical  pulsation.  The 
veins  are  increased  in  size.  This  is  more  noticeable  during  the  act  of 
coughing  or  when  the  patient  holds  his  breath  in  full  inspiration.  In 
rare  instances  the  pulsation  is  transmitted  to  the  subclavian  and  axil- 
lary veins. 

The  regurgitant  pulsation  is  transmitted  to  the  ascending  vena  cava 
as  well  as  to  the  descending.  The  hepatic  veins  also  distend  during 
the  systole.  So-called  pulsation  of  the  liver  is  produced.  With  one 
hand  on  the  fifth  and  sixth  costal  cartilages  and  the  other  over  the 
liver  in  the  axillary  region,  rhythmical  expansile  pulsation  may  be 
recognized.  It  is  not  of  common  occurrence,  but  is  absolutely  diag- 
nostic of  regurgitation  at  the  tricuspid  orifice. 

Palpation.  By  palpation  the  above  conditions  are  also  determined. 
The  impulse  over  the  lower  sternum  and  in  the  epigastrium  is  noted 
to  be  forcible. 

Percussion.  The  area  of  cardiac  dulness  is  increased  transversely 
and  upward,  as  described  in  mitral  stenosis.  It  extends  often  far 
beyond  the  right  edge  of  the  sternum. 

Auscultation.  At  the  xiphoid  cartilage,  the  lower  end  of  the  ster- 
num, or  the  head  of  the  fourth  rib  a  murmur  is  heard.  It  is  systolic 
in  time,  usually  low  in  pitch,  and  is  heard  loud  to  the  left  of  the 
sternum,  within  an  inch  of  the  apex,  and  to  the  right  of  the  sternum 
and  the  outer  limits  of  percussion-dulness.  (See  Fig.  78.)  It  is  not 
further  transmitted.  Other  murmurs  are  heard  due  to  the  primary 
organic  disease.  If  the  heart  is  weak,  the  lesion  may  not  be  produc- 
fcive  of  a  murmur.      The  pulmonary  second  sound  is  accentuated. 

Tricuspid  Stenosis.  Stenosis  at  this  valve-orifice  is  generally  of 
congenital  origin.  In  rare  instances  it  may  be  secondary  to  lesions  in 
the  left  heart.  It  is  accompanied  by  dilatation  of  the  right  auricle 
The  physical  signs  are  the  same  as  in  stenosis  at  the  mitral  orifice, 
except  for  the  alteration  in  their  position.  In  some  instances  a  presys- 
tolic thrill  has  been  observed  and  with  it  a  presystolic  murmur  at  the 
lower  end  of  the  sternum  or  toward  the  right  of  it.  The  area  of  dul- 
ness is  increased  as  in  right-sided  dilatation.  Cyanosis  is  a  very  prom- 
inent symptom  and  may  be  very  intense. 

Disease  of  the  Pulmonary  Valve.  Diseases  of  the  pulmo- 
nary valve  are  extremely  rare  and  are  almost  always  congenital. 


438  SPECIAL  DIAGNOSIS. 

Pulmonary  Stenosis.  In  stenosis  of  the  pulmonary  valve  a  sys- 
tolic murmur  and  thrill  are  detected  to  the  left  of  the  sternum  in  the 
second  interspace.  The  murmur  is  not  transmitted  to  the  vessels  of 
the  neck.  The  pulmonary  second  sound  is  weak.  The  effect  on  the 
heart  is  the  production  of  right-sided  hypertrophy. 

Pulmonary  Insufficiency.  The  physical  signs  are  due  to  regur- 
gitation into  the  right  ventricle.  The  maximum  intensity  of  the  mur- 
mur is  in  the  second  pulmonary  interspace,  and  it  is  transmitted  down 
the  sternum.  It  cannot  be  distinguished  from  aortic  regurgitation, 
except  by  the  pulse. 

Combined  Valvular  Lesions.  It  must  not  be  forgotten  that 
there  may  be  disease  causing  both  obstruction  and  regurgitation  at  the 
same  time  and  at  the  same  orifice,  or  that  two  or  more  valves  may  be 
the  seat  of  disease  in  the  same  individual.  It  is  not  impossible,  for 
instance,  to  have  aortic  obstruction  and  regurgitation,  mitral  obstruc- 
tion and  regurgitation,  and  tricuspid  regurgitation.  Aortic  obstruction 
or  insufficiency  is  frequently  combined  with  mitral  insufficiency.  Aortic 
and  mitral  insufficiency  occur  together  most  frequently  in  children; 
aortic  obstruction  and  mitral  obstruction  in  adults. 

When  more  than  one  valve  is  diseased  the  site  of  the  various 
lesions  is  based  upon  the  time  of  the  murmurs,  the  position  of  their 
maximum  intensity,  and  the  direction  of  their  transmission.  Students 
often  experience  difficulty  here.  A  systolic  murmur  may  be  heard  in 
the  aortic  area  and  in  the  mitral  area  at  the  same  time.  If  it  is  observed 
that  each  progressively  weakens  as  the  stethoscope  is  moved  toward  the 
middle  of  the  precordial  area,  it  may  be  inferred  that  the  murmur, 
systolic  in  time,  is  due  to  two  lesions.  As  previously  intimated,  the 
direction  of  the  transmission  of  the  murmur  further  aids  in  the  diasr- 
nosis. 

Enlargement  of  the  Heart. 

Enlargement  of  the  heart  is  due  to  hypertrophy  or  to  dilatation.  In 
hypertrophy  there  is  increased  thickness  of  the  muscular  walls.  This 
may  be  general  or  limited  to  the  walls  of  one  chamber.  Hypertrophy  is 
further  divided  into  simple  hypertrophy,  in  which  the  cavity  or  cavi- 
ties are  of  normal  size,  and  eccentric  hypertrophy,  in  which,  with 
increase  in  the  wall,  there  is  enlargement  of  the  cavities.  This  is 
hypertrophy  with  dilatation.  The  left  ventricle  is  most  frequently  the 
seat  of  hypertrophy  when  one  chamber  is  involved.  The  cause  of 
hypertrophy  is  obstruction  to  the  flow  of  blood  ;  increased  work  is 
followed  by  increased  size  of  the  muscle.  General  hypertrophy  or 
hypertrophy  of  the  left  ventricle  occurs  from  diseases  of  the  heart  itself, 
or  from  affections  of  the  bloodvessels. 

A.  Diseases  of  the  heart.  1.  Disease  of  the  aortic  valves.  Hyper- 
trophy of  the  left  ventricle  always  follows.  2.  Mitral  regurgitation. 
3.  Pericardial  adhesions.  4.  Myocarditis  of  the  fibrous  variety. 
5.  Neuroses  with  overaction  and  frequent  palpitation,  as  in  exophthal- 
mic goitre  and  from  the  effects  of  tea,  tobacco,  and  alcohol.  In  peri- 
cardial adhesions  and  myocarditis  hypertrophy  arises  because  of  the 
inability  of  the  heart  to  do  the  work  expected  of  it.     There  is  no 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     439 

obstruction  in  the  course  of  the  vessels  or  at  the  orifices.  The  struggle 
to  keep  up  causes  the  hypertrophy.  In  neuroses  there  is  absence  of 
obstruction,  but  the  rapid  action  causes  hypertrophy. 

B.  Affections  of  the  bloodvessels  which  cause  hypertrophy  are  :  1. 
General  arterial  sclerosis.  2.  Increased  arterial  tension  due  to  contrac- 
tion of  the  peripheral  arteries,  as  in  Bright' s  disease,  and  in  toxaemias 
from  lead,  the  poison  of  gout  and  of  syphilis.  3.  Increased  blood-pres- 
sure from  prolonged  muscular  exertion.  4.  Narrowing  of  the  aorta 
from  external  pressure  and  from  congenital  stenosis  or  the  development 
of  an  aneurism. 

Hypertrophy  of  the  Right  Ventricle.  In  hypertrophy  of  the  right 
ventricle  obstruction  to  the  flow  of  blood  throughout  the  pulmonary 
area  is  the  causal  condition.  This  occurs  because  of  lesions  of  the 
mitral  valve,  causing  pulmonary  stasis;  and  disease  of  the  lungs,  caus- 
ing compression  of  the  bloodvessels,  as  in  emphysema  or  cirrhosis.  It 
occurs  if  there  is  disease  of  the  right  heart  with  obstruction  of  the  valves. 

In  obstruction  at  the  pulmonary  orifice  the  right  ventricle  undergoes 
secondary  hypertrophy. 

Hypertrophy  of  the  Auricles.  Simple  hypertrophy  of  the  left  auricle 
with  dilatation  develops  in  mitral  stenosis.  Hypertrophy  of  the  right 
auricle  occurs  in  right-sided  dilatation  with  tricuspid  regurgitation. 

Symptoms.  The  symptoms  of  hypertrophy  of  the  heart  are  general 
and  local.  The  former  are  not  common.  They  are  due  to  increased 
force  of  the  circulation  through  the  brain,  usually  causing  congestive 
headaches,  with  noises  in  the  ears,  flashes  of  light,  and  flushing  of  the 
face. 

General  symptoms  arise  in  the  course  of  hypertrophy  of  the  left  ven- 
tricle on  account  of  the  effect  of  the  increased  force  upon  the  vascular 
system.  In  Bright' s  disease,  for  instance,  or  heightened  arterial  ten- 
sion from  other  causes,  endarteritis  develops  in  the  large  vessels  on 
account  of  the  strain  put  upon  them.  This  is  seen  particularly  in  the 
aorta  and  its  divisions.  Whether  atheroma  is  primary  or  secondary, 
its  presence,  with  hypertrophy  of  the  left  ventricle,  indicates  that  rup- 
ture of  the  vessels  somewhere  in  the  periphery  may  take  place.  This 
occurs  most  frequently  in  the  brain,  causing  apoplexy. 

Locally  the  patient  complains  of  fulness  and  discomfort,  particularly 
marked  when  lying  down  on  the  left  side.  In  the  hypertrophy  that 
accompanies  the  tobacco-heart,  or  the  irritable  heart  of  soldiers,  there 
may  be  some  pain.  The  organ  may  be  enormously  enlarged  without 
the  patient  complaining  of  discomfort  about  the  heart.  Palpitation  is 
not  of  common  occurrence  except  in  neurasthenic  subjects. 

Physical  Signs.  The  hypertrophy  causes  precordial  bulging,  if  it 
has  developed  early  in  life,  when  the  ribs  are  soft.  The  intercostal 
spaces  are  widened  and  the  area  of  impulse  is  much  increased.  The 
normal  impulse  is  changed  in  position.  The  hypertrophy  of  the  left 
ventricle  is  downward  and  to  the  left,  extending  as  far  as  the  axilla. 

Palpation.  The  impulse  is  forcible  and  heaving.  The  head  is  visi- 
bly raised  with  each  systole  when  placed  upon  the  chest  for  ausculta- 
tion. The  impulse  is  slow.  This  slow,  heaving  impulse  distinguishes 
it  from  the  forcible  impulse  of  dilated  hypertrophy,  which  is  sudden  and 


440  SPECIAL  DIAGNOSIS. 

abrupt.  Inspection  is  confirmed  as  to  the  position  of  the  apex.  In 
moderate  hypertrophy  the  apex  extends  to  the  sixth  interspace  in  the 
midclavicular  line.  In  large-sized  hypertrophy  it  may  extend  to  the 
seventh  interspace.  The  heart  may  be  hypertrophied,  and  yet  the 
impulse  may  be  absent  in  a  weakly  acting  heart,  in  emphysema,  in  fatty 
overgrowth  of  the  heart,  and  in  persons  with  thick  chest- walls. 

Percussion.  The  area  of  dulness  is  increased  both  upward  and  trans- 
versely. It  may  begin  as  high  as  the  second  interspace  and  extend 
two  inches  beyond  the  left  mid-clavicular  line,  and  an  inch  beyond 
the  right  edge  of  the  sternum  transversely.  In  simple  hypertrophy 
the  area  is  ovoid. 

Auscultation.  When  the  valves  are  healthy,  prolongations  of  the 
first  sounds  occur.  They  are  also  at  times  duller  than  in  health. 
The  dull,  prolonged  first  sounds  distinguish  hypertrophy  from  dila- 
tation, in  which  the  same  sounds  are  clear  and  sharp.  The  second 
sounds  are  clear  and  loud.  The  degree  of  accentuation  depends  upon 
the  state  of  the  peripheral  arteries.  If  there  is  heightened  tension,  the 
second  sound  may  be  reduplicated.  If  valvular  disease  is  present, 
the  sounds  are  modified. 

The  Pulse.  The  frequency  of  the  pulse  is  not  modified.  It  is  full, 
regular,  and  strong.  The  tension  is  increased.  In  dilated  hypertrophy 
the  pulse  is  full  but  soft,  and  more  rapid  than  in  simple  hypertrophy. 
When  failure  of  the  heart  takes  place  the  pulse  increases  in  frequency 
and  becomes  intermittent  and  irregular.  When  valve-lesions  are  present 
the  pulse  is  modified  accordingly. 

Hypertrophy  of  the  Right  Ventricle.  Increased  pulmonary  tension 
from  resistance  in  the  pulmonary  circulation  may  always  be  looked  for. 
If  there  is  complete  compensation,  no  symptoms  are  observed,  or  only 
those  of  dyspnoea  on  extra  exertion.  Hypertrophy  of  this  ventricle 
persists  for  a  long  period  of  time  without  the  grave  local  changes  in  the 
heart,  or  secondary  changes  in  the  peripheral  vessels,  which  occur  in 
left  ventricle  hypertrophy.  In  dilated  hypertrophy,  when  the  dilata- 
tion is  in  excess,  tricuspid  regurgitation  takes  place,  with  the  develop- 
ment of  venous  stases.  Induration  of  the  lungs  succeeds  the  engorge- 
ment of  the  capillaries  in  dilated  hypertrophy.  When  the  dilatation 
is  excessive,  pulmonary  congestions  and  apoplexy  are  associated. 

The  Physical  Signs  of  hypertrophy  of  the  right  ventricle  have  been 
partially  referred  to  under  the  various  valve  affections.  There  is  bulg- 
ing of  the  lower  part  of  the  sternum  and  cartilages.  The  epigastric 
impulse  in  the  angle  between  the  ensiform  cartilage  and  the  ribs  has 
been  referred  to.  The  impulse  may  be  in  the  sixth  interspace.  It  is 
diffuse  ;  it  may  extend  upward  as  in  mitral  stenosis.  Cardiac  dulness 
is  increased  toward  the  right  an  inch  or  more  beyond  the  border  of  the 
sternum.  The  heart-sounds  are  not  much  changed  unless  there  is  dila- 
tation. The  tricuspid  sound  is  clear  and  sharp  when  this  occurs.  The 
pulmonary  second  sound  is  accentuated,  and  reduplication  may  take 
place.  The  radial  pulse  is  small.  If  there  is  tricuspid  regurgitation, 
the  physical  signs  that  attend  it  are  present. 

Hypertrophy  of  the  Left  Auricle.  This  is  present  in  mitral  stenosis, 
but  cannot  be  determined  by  physical  signs,  save  possibly  by  greater 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     441 

increase  of  dulness  to  the  left  of  the  sternum  in  the  second  and  third 
interspaces.  Barr  states  that  dulness  above  the  "suprasternal  mam- 
millary  line"  toward  the  left  clavicle  indicates  enlargement  of  the  left 
auricle,  as  in  mitral  stenosis.  The  line  above  mentioned  is  drawn 
from  the  middle  of  the  suprasternal  notch  to  the  normal  site  of  the 
left  nipple  on  the  fourth  rib.  Hypertrophy  of  the  right  amide  with 
dilatation  occurs  under  the  same  circumstances  as  hypertrophy  of  the 
ventricle.  It  usually  dilates  more  than  the  left  auricle  in  left  ventricle 
hypertrophy.  There  is  increased  area  of  dulness  in  the  third  and 
fourth  right  interspaces;  abnormal  pulsation  is  sometimes  observed  in 
this  situation  before  the  systole,  with  the  signs  of  tricuspid  regurgi- 
tation. 

Diagnosis.  The  forcible  impulse  that  occurs  in  nervous  palpitation 
of  the  heart  must  not  be  confounded  with  true  hypertrophy,  although 
it  must  not  be  forgotten  that  hypertrophy  frequently  follows  neurotic 
palpitation,  as  in  the  smoker's  heart,  or  in  exophthalmic  goitre.  The 
enlargement  must  not  be  confounded  with  enlargement  of  the  area  of 
cardiac  dulness  in  the  precordial  region  from  other  causes,  such  as  peri- 
cardial effusion;  aneurism  and  mediastinal  tumor,  pushing  the  heart 
against  the  chest-wall  ;  disease  of  the  lungs,  on  account  of  which  they 
are  withdrawn  from  the  surface  of  the  heart,  as  in  phthisis  or  chronic 
pleurisy;  and  displacement  of  the  heart  from  pressure,  as  in  effusion  on 
the  left  side  of  the  chest,  or  in  disease  below  the  diaphragm.  The 
cause  of  hypertrophy  should  be  ascertained,  for  it  is  a  valuable  aid  in 
diagnosis.  It  must  nut  be  forgotten  that  emphysema  of  the  lung  may 
mask  a  considerable  hypertrophy  of  the  heart  by  causing  diminution 
of  the  area  of  dulness. 

Dilatation  of  the  Heart.  Enlargement  due  to  dilatation  of 
the  heart  is  common.  The  condition  usually  succeeds  hypertrophy. 
Thickening  of  the  muscles  attends  dilatation  of  the  cavities,  as  in 
dilated  or  eccentric  hypertrophy.  The  dilatation  occurs  because  of 
increased  pressure  within  the  cavities  or  because  of  weakening  of  the 
heart- walls,  the  pressure  within  being  normal. 

1.  Increased  pressure  within  the  walls  is  due  to  an  increased  amount 
of  blood  within  the  chamber  from  regurgitation,  or  from  an  obstacle 
to  the  outward  flow  of  blood.  Simple  hypertrophy  occurs  first  in  many 
cases  ;  in  others,  hypertrophy  with  dilatation  ;  in  not  a  few,  dilatation 
at  once  takes  place.  In  dilatation  the  chamber  does  not  empty  itself 
during  the  systole.  It  is  seen  physiologically  after  the  exertion  of 
ascending  a  great  height.  It  may  remain  within  the  bounds  of  physi- 
ological action.  The  dilatation  is  attended  by  increased  epigastric  pul- 
sation, and  sometimes  by  increase  in  cardiac  dulness.  The  tricuspid 
valves  temporarily  become  incompetent,  owing  to  their  safety-valve 
action.  It  may  continue  after  the  acute  strain,  the  heart  always  show- 
ing symptoms  of  the  condition,  or  it  may  disappear  entirely.  The  ex- 
cessive dilatation  that  sometimes  follows  results  in  heart-strain,  witli 
the  cardiac  distress  of  which  dyspnoea  is  associated.  Acute  dilatation 
from  overdistention  and  paralysis  of  the  heart  occurs  (see  Symptoms). 
Dilatation  occurs  in  all  forms  of  heart-lesions  which  have  been  previ- 
ously described.    The  most  typical  form  occurs  in  aortic  regurgitation, 


442  SPECIAL  DIAGNOSIS. 

when  the  left  ventricle  becomes  the  seat  of  dilatation,  and  in  mitral 
reo-urffitation  when  the  left  auricle  becomes  the  seat  of  dilatation. 

2.  Disease  of  the  heart- walls,  lessening  the  resisting  power,  the 
normal  pressure  within  the  cavities  being  maintained,  precedes  dilata- 
tion. In  the  myocarditis  that  occurs  in  the  course  of  fevers  acute 
dilatation  may  ensue.  It  occurs  in  scarlatiual  dropsy,  typhoid  fever, 
rheumatic  fever,  and  erysipelas.  The  heart-muscle  changes  in  acute 
endo-  and  pericarditis,  on  accouut  of  which  dilatation  may  ensue.  In 
anaemia  and  chlorosis  the  same  process  may  take  place.  In  chronic 
myocarditis  dilatation  takes  place  at  the  apex.  When  pericardial  adhe- 
sions are  present,  the  fibrous  overgrowth  invades  the  interstices  of  the 
myocardium,  thereby  weakening  the  heart-muscle.  Dilatation  may 
follow. 

Symptoms.  The  symptoms  of  dilatation  are  the  reverse  of  those  of 
hypertrophy.  When  the  latter  fails  the  blood  is  not  expelled  from 
the  chambers  in  the  systole,  so  that  the  chamber  is  overdistended  with 
blood  that  accumulates  in  the  diastole.  Weakening  of  the  muscles 
also  favors  the  development  of  dilatation.  As  soon  as  dilatation  be- 
comes permanent,  incompetency  of  the  valves  takes  place.  In  obstruc- 
tive heart  disease  the  left  side  is  first  affected.  It  may  be  compensated 
for  by  hypertrophy  of  the  right  side.  When  this  fails  venous  engorge- 
ment and  dropsy  ensue.  The  symptoms  have  been  described  under 
chronic  valvular  disease.  In  acute  dilatation  there  is  a  sudden  occur- 
rence of  dyspnoea.  Pain,  or  at  lea-t  precordial  oppression,  may  be 
complained  of.  The  heart's  action  increases  in  frequency.  The  pulse 
is  rapid,  feeble,  irregular,  and  may  scarcely  be  felt  at  the  wrist. 

Physical  Signs.  Inspection.  The  apex  is  displaced  to  the  left,  even 
as  far  as  the  axillary  line,  but  rarely  downward,  unless  hypertrophy 
precedes  the  dilatation.  The  impulse  is  diffused  and  undulatory  in 
appearance.  The  apex-beat  may  be  denned  with  extreme  difficulty. 
It  may  be  visible  when  the  patient  leans  forward,  yet  not  felt. 

Palpation.  With  the  diffused  area  of  impulse  a  quick  apex-beat 
may  be  felt  —much  weakened,  however.  When  the  right  ventricle  is 
dilated  the  impulse  is  seen  and  felt  to  the  right  or  left  of  the  xiphoid 
cartilage,  and  there  is  a  wavy  pulsation  along  the  left  edge  of  the 
sternum  in  the  fourth,  fifth,  and  sixth  interspaces.  If  the  dilatation 
is  extreme,  involving  the  right  auricle,  a  pulsation  at  the  third  right 
interspace  close  to  the  sternum  may  be  felt.  Tricuspid  regurgitation 
is  then  present. 

Percussion.  The  area  of  dulness  is  increased  in  the  same  directions 
as  in  hypertrophy,  if  the  two  coexist.  In  general,  it  may  be  said  the 
increase  extends  outward  to  the  right  or  .left,  the  direction  correspond- 
ing to  the  ventricle  affected.  It  is  increased  upward  along  the  left 
edge  of  the  sternum  in  left  auricle  dilatation.  (See  Mitral  Valvulitis.) 
When  the  whole  heart  is  dilated  the  increase  of  dulness  is  in  a  trans- 
verse direction  on  both  sides.  The  apex  is  rounded  or  square,  not 
pointed  as  in  hypertrophy  ;  indeed,  it  retains  the  oval  shape  of  the 
dulness  of  a  normal  heart.  As  dilatation  occurs  so  frequently  in 
emphysema  of  the  lungs,  the  modification  of  the  percussion-sound  must 
be  remembered. 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     443 

Auscultation.  The  systolic  sounds  are  short  and  sharp.  They  are 
high-pitched  and  resemble  the  diastolic.  The  latter  may  become 
enfeebled  when  the  dilatation  becomes  excessive.  The  right  and  left 
first  sounds  may  differ  somewhat  in  intensity,  and  reduplication  may 
occur.  The  sounds  may  be  obscured  by  murmurs.  The  murmurs 
are  due  to  previous  valve  disease  or  to  incompetency  on  account  of 
dilatation.  The  action  of  the  heart  is  irregular  and  intermittent. 
The  pulse  is  correspondingly  small.  In  dilatation  the  alteration  of 
the  rhythm  is  extreme.  There  may  be  embryocardia  or  foetal-heart 
rhythm,  in  which  the  first  and  second  sounds  are  alike,  and  the  long- 
pause  is  shortened.  More  frequently  Ave  have  galloping  rhythm  of 
the  heart.  It  must  not  be  forgotten  that,  as  dilatation  ensues,  murmurs 
of  various  valve-lesions  may  disappear,  particularly  the  murmur  of 
mitral  stenosis.  On  the  other  hand,  in  the  earlier  stages  particularly, 
murmurs  develop  on  account  of  incompetency  at  the  auriculo-ventric- 
ular  orifices,  in  addition  to  the  primary  organic  murmur.  These  mur- 
murs in  turn  may  disappear,  if  the  dilatation  is  controlled  by  careful 
treatment. 

Congenital  Heart  Disease. 

Cyanosis  is  the  chief  symptom  of  congenital  heart  disease.  The 
terms  blue  disease  and  morbus  coeruleus  are  used  as  synonyms  for  this 
condition.  The  lividity  appears  in  the  first  week  of  life.  It  may  be 
general  or  confined  to  distant  points  of  the  circulation.  In  extreme 
grades  the  skin  is  almost  purple.  It  may  vary  from  time  to  time,  and 
be  intense  on  exertion.  The  external  temperature  is  below  normal. 
If  the  child  remains  quiet,  there  may  be  no  symptoms  of  dyspnoea  ; 
dyspnoea  and  cough  occur  if  it  is  moved  about,  or  on  exertion  when 
the  child  is  older.  The  physical  development  is  very  poor,  the  mind 
is  sluggish.  Clubbing  of  the  fingers  and  toes  takes  place  to  a  high 
degree.  The  recognition  of  the  condition  in  children  is  not  difficult. 
If  a  murmur  is  found  in  a  patient  with  cyanosis  during  the  early  weeks 
of  life,  it  is  due  to  congenital  heart  disease.  The  murmur  is  usually 
systolic  in  time.  Hypertrophy  occurs  in  a  number  of  cases.  In  some 
instances  the  murmur  is  absent. 

Diseases  of  the  Arteries. 

Arterial  Sclerosis  or  Arterio-capillary  Fibrosis,  This 
occurs  as  the  result  of  wear  and  tear  of  life  and  as  the  accompanimenl 
of  age.  The  time  of  its  onset  depends  upon  the  quality  of  the 
arterial  tissue  which  the  individual  inherited,  and  upon  the  amount 
of  wear  and  tear.  It  may  occur  early  in  life,  and  entire  families  may 
show  this  tendency.  Very  frequently  the  sclerosis  develops  from  intox- 
ications of  the  system,  on  account  of  which  persistent  spasm  of  the 
small  vessels  is  set  up  ;  for  blood  of  an  impaired  quality  is  passed  with 
greater  difficulty  through  the  eapillaries,  as  was  taught  by  Bright.  The 
blood-tension  is  raised  thereby.  The  poison  of  alcohol,  of  lead,  of  gout, 
and  of  syphilis  leads  to  this  condition.  The  poison  of  syphilis  ami  of 
gout  may  set  up  directly  an  inflammation  and  degeneration  of  the  arteries. 


444  SPECIAL  DIAGNOSIS. 

In  renal  disease  arterial  sclerosis  is  of  common  occurrence.  The  rela- 
tion to  the  renal  lesion  differs.  It  may  be  primary  or  secondary. 
When  primary,  the  morbid  cause  operates  upon  the  kidneys  as  well  as 
the  arteries.  When  secondary  a  morbid  poison  is  retained  within  the 
system  by  the  diseased  kidneys,  the  action  of  which  is  such  as  to  cause 
peripheral  spasm  and  heightened  tension. 

Overfilling  of  the  bloodvessels  from  excessive  eating  and  drinking  is 
thought  by  some  to  cause  arterial  sclerosis  through  constant  overdisten- 
tion  of  the  vessels.  In  overwork  of  the  vessels  and  excessive  strain 
there  is  either  heightened  tension  or  increased  peripheral  resistance,  in 
either  case  the  effect  upon  the  bloodvessels  is  the  same.  The  result 
of  the  above  causes  is  thickening  of  the  intima  of  the  bloodvessels  fol- 
lowed by  changes  in  the  media  and  adventitia,  terminating  in  endar- 
teritis deformans  of  the  large  arteries. 

Symptoms.  The  symptoms  vary.  They  may  be  general  or  local. 
The  disease  may  be  present  and  the  patients  die  from  other  causes,  and 
yet  the  general  arterial  system  is  found  to  be  the  seat  of  extensive  dis- 
ease. The  local  symptoms  are  due  to  the  local  giving  way  of  the  ves- 
sels in  one  part,  as  occurs  in  apoplexy  from  cerebral  hemorrhage,  or 
the  blocking  of  the  coronary  artery,  or  the  rupture  of  an  aneurism. 

Physical  Signs.  Arterio-sclerosis  is  recognized  by  inspection,  palpa- 
tion, and  auscultation  of  the  bloodvessels,  and  by  observation  of  the 
condition  of  the  heart.  The  superficial  bloodvessels  are  elongated  and 
tortuous,  and  pulsate  visibly.  On  palpation  the  artery  feels  very  hard 
to  the  touch  ;  it  resists  compression  ;  it  is  corded  or  rounded  under- 
neath the  finger,  and  readily  rolled  about.  The  pulse  shows  at  once 
high  tension  ;  the  wave  is  slow  in  ascent,  continues  long  underneath 
the  finger,  and  subsides  slowly.  If  in  the  intervals  of  the  beats  the 
vessel  remains  full,  the  pulse,  as  previously  noted,  is  obliterated  with 
difficulty.  Sphygmographic  tracings  are  characteristic  (see  Pulse). 
If,  after  pressure  on  the  radial  artery,  it  can  still  be  felt  beyond  the 
point  of  compression,  its  walls  are  sclerosed;  whereas,  if  after  such 
compression  the  artery  is  obliterated  beyond  the  point  of  compression, 
the  hardness  and  firmness  of  the  pulse  previously  observed  are  due 
to  vascular  tension  and  not  to  thickened  walls.  The  two  conditions 
should  be  distinguished.  Hypertrophy  of  the  heart  occurs  early  in  the 
course  of  the  sclerosis  on  account  of  p  'ripheral  resistance.  The  hyper- 
trophy involves  the  left  ventricle,  and  is  not  attended  by  dilatation. 
The  apex-beat  is  out  beyond  the  mid-clavicular  line  ;  the  impulse  is 
heaving  and  forcible.  Very  characteristic  is  the  occurrence  of  the  second 
sound  at  the  aortic  cartilage.  It  is  clear  and  ringing  ;  it  is  heard  in 
the  course  of  the  bloodvessels,  and  is  most  distinct  at  or  beyond  the 
apex  near  the  heart.  Right-sided  hyp?rtrophy  and  dilatation  are  not 
generally  present.  Auscultation  of  the  larger  arteries,  as  the  carotids, 
the  abdominal  aorta,  and  femorals,  shows  a  systolic  murmur  usually 
rough  and  high  in  pitch.  All  the  above-mentioned  conditions  may  be 
present,  and  yet  the  patient  remain  in  good  health.  The  hypertrophy 
apparently  compensates  for  the  arterial  occlusion.  There  may  be  no 
renal  disease,  or  moderate  renal  cirrhosis  may  be  present,  indicated  by 
a  transient  albuminuria,  polyuria,  and  hyaline  tube-casts.      The  subse- 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     440 

quent  symptoms  are  due  largely  to  closure  of  one  or  more  vessels  in 
the  peripheral  circulation,  to  the  development  of  an  aneurism  or  dila- 
tation of  the  aorta,  to  failing  hypertrophy  of  the  heart,  or  to  the 
development  of  renal  cirrhosis. 

The  blocking  of  peripheral  arteries  is  due  to  embolism  or  throm- 
bosis, more  frequently  the  latter,  and  to  rupture  of  peripheral  vessels, 
or,  in  all  probability,  miliary  aneurisms.  When  occlusion  of  the  vessels 
takes  place  in  arteries  which  supply  the  extremities  gangrene  may 
occur.  Sometimes  the  occlusion  is  due  to  simple  narrowing  of  the 
vessels  alone.  Gangrene  of  the  feet  is  frequently  seen  secondary  to 
bad  arteries.  If  the  occlusion  takes  place  in  the  vessels  of  the  brain, 
various  secondary  lesions  are  produced.  In  more  or  less  general  occlu- 
sion from  sclerosis  of  the  smaller  arteries  acute  and  chronic  softening- 
occur.  Hemiplegia,  monoplegia,  or  aphasia  may  occur  temporarily, 
if  relieved  by  collateral  circulation,  or  permanently,  from  embolism, 
thrombosis,  or  rupture  of  the  vessels.  Hence  apoplexy  is  almost  always 
due  to  primary  disease  of  the  arteries,  upon  which,  in  the  large 
majority  of  cases,  miliary  aneurisms  have  existed.  If  the  coronary 
arteries  are  blocked,  thrombosis  with  sudden  death  takes  place,  or 
chronic  myocarditis  may  develop,  with  subsequent  aneurism  and  rupt- 
ure. Angina  pectoris,  with  or  without  thrombosis  of  the  coronary 
artery,  is  always  associated  with  arterial  sclerosis. 

Failure  of  the  hypertrophi*  d  heart  leads  to  dilatation  with  all  the 
symptoms  as  previously  described,  including  cyanosis,  visceral  conges- 
tions, and  dropsies.  The  murmur  at  the  apex,  due  to  incompetency  from 
dilatation,  may  simulate  chronic  valvular  disease,  although  the  latter 
may  never  have  been  present.  The  sclerosis  may  advance  more  rapidly 
in  the  kidneys  than  in  the  other  portions  of  the  circulatiou ;  later,  on  ac- 
count of  the  contracted  kidney,  symptoms  of  interstitial  nephritis  arise. 

Aneurism. 

A  true  aneurism  is  formed  by  the  distention  of  one  or  more  of  the 
arterial  coats.  It  is  usually  fusiform,  but  may  be  cylindrical.  It 
may  be  circumscribed  or  sacculated.  The  fusiform  and  saccular  are 
the  forms  most  commonly  seen.  False  aneurism  or  dissecting-aneurism 
arises  from  laceration  of  the  internal  coat  of  the  artery.  The  blood 
dissects  between  the  layers.  It  occurs  in  the  aorta.  It  may  begin 
at  the  heart  and  separate  the  coats  as  far  down  as  the  iliac  arteries. 
Arterio-venous  aneurism  is  seen  when  communication  between  an 
artery  and  a  vein  has  been  set  up.  If  the  sac  intervenes,  it  is  called 
a  varicose  aneurism.  Sometimes  communication  is  direct,  the  vein  be- 
coming dilated,  tortuous,  and  pulsating.  It  is  known  as  an  aneurismal 
varix. 

An  aneurism  may  occur  in  the  course  of  arterial  sclerosis  from 
diffuse  distention  of  the  coats.  Its  typical  form  is  seen  in  dilatation 
of  the  aorta  witli  one  or  more  sacculated  aneurisms  on  its  surface. 
Sacculated  aneurism  occurs  from  rupture  of  the  tunica  media,  indepen- 
dently of  general  disease  of  the  arteries,  and  in  arterial  sclerosis.  The 
most  common   seat  is  the  ascending  portion  of  the  aorta.      It  occur- 


446 


SPECIAL  DIAGNOSIS. 


early  in  the  course  of  arterial  sclerosis.  Such  form  of  aneurism  is 
seen  in  the  smaller  vessels.  Aneurisms  also  arise  after  the  lodgement 
of  an  embolus,  permanently  plugging  the  vessel.  The  proximal  end 
of  the  vessel  becomes  dilated. 

Mycotic  aneurism,  first  described  by  Osier  and  exhaustively  by  Eppin- 
ger,  occurs  in  malignant  endocarditis.  The  aneurisms  are  small  in 
size  and  multiple,  not  generally  recognized  during  life.  They  arise 
from  the  injury  produced  by  the  local  infection  of  bacteria  in  different 
portions  of  the  vascular  system. 

Aneurism  of  the  Aorta.  The  causes  which  produce  arterial  scle- 
rosis are  operative  in  the  thoracic  portion  of  the  aorta — chiefly  physical 


Fig.  92. 


Aneurism  ot  ascending  portion  of  arch  of  aorta.    Tumor  in  first  and  second  interspaces, 
extending  into  neck.    Portion  of  sternum  atrophied. 

overwork,  alcohol,  syphilis,  and  gout.      In  this  portion  of  the  aorta  it 
may  be  situated  just  beyond  the  aortic  ring,  at  the  junction  of  the 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     447 

ascending  and  transverse  aorta,  in  the  transverse,  or  at  the  beginning 
of  the  descending  portion.  The  larger  aneurisms  are  at  the  two  bends 
of  the  aorta. 

Symptoms.  The  symptoms  of  aneurism  are  largely  due  to  pressure 
and  depend  upon  the  position  of  the  aneurism  and  the  direction  of  its 
growth. 

Aneurisms,  however,  may  exist  without  symptoms  or  appreciable 
physical  signs.  Even  in  a  patient  who  has  been  under  careful  obser- 
vation, sudden  death  may  take  place  from  rupture  of  a  concealed  aneu- 
rism, the  presence  of  which  had  not  been  suspected  during  life.  On 
the  other  hand,  cases  occur  with  characteristic  pressure-symptoms  and 
with  no  physical  signs.  Pressure-symptoms  depend  entirely  upon  the 
position  of  the  tumor. 

Aneurisms  of  the  ascending  portion  of  the  arch  cause  dislocation  of 
the  heart  outward,  or  toward  the  right  pleura  or  forward,  appearing 
at  the  second  or  third  interspace,  causing  erosion  of  the  ribs  and 
sternum.  The  vena  cava  is  compressed,  causing  enlargement  of  the 
veins  of  the  head  and  arms  ;  the  subclavian  vein  may  be  compressed 
alone,  causing  enlargement  and  oedema  of  the  right  arm.  Local- 
ized oedema  may  result,  coufiued  1o  the  thorax  (see  (Edema).  If  the 
aneurism  is  large,  the  inferior  vena  cava  may  be  pressed  upon,  causing 
oedema  of  the  feet.  The  right  laryngeal  nerve  may  be  involved,  caus- 
ing aphonia  and  dyspnoea.      Pain  attends  the  aneurismal  process. 

Aneurisms  of  the  transverse  portion  of  the  aorta  project  below,  for- 
ward, or  backward.  When  forward,  they  produce  tumors  behind  the 
manubrium  which  from  pressure  cause  destruction  of  the  bone  ;  if  the 
aneurism  projects  backward,  marked  pressure-symptoms  are  produced. 
When  the  trachea  is  pressed  upon,  it  causes  dyspnoea  and  cough,  which 
is  paroxysmal  (see  Dyspnoea).  The  oesophagus  may  be  pressed  upon, 
causing  dysphagia.  The  left  recurrent  laryngeal  nerve  may  be  pressed 
upon,  causing  paralysis  of  the  corresponding  cord,  with  aphonia  (see 
Larynx).  Pressure  on  a  bronchus  may  produce  bronchorrhoea  and 
dilatation,  which  in  turn  may  lead  to  localized  abscess.  The  growth 
may  extend  upward,  involving  the  coats  of  the  innominate  and  carotid 
arteries  on  the  right  side,  or  carotid  and  subclavian  on  the  left,  mark- 
edly interfering  with  the  pulse  of  the  two  sides.  Pressure  on  the  sym- 
pathetic nerve  is  likely  to  take  place  in  this  situation,  with  contraction 
of  one  of  the  pupils,  although  at  first  it. is  sometimes  dilated.  The 
thoracic  duct  is  sometimes  compressed,  leading  to  rapid  wasting. 

In  the  descending  portion  the  pressure-signs  of  aneurism  are  not  so 
marked.  The  vertebrae  are  likely  to  be  pressed  upon  in  this  situation. 
The  pain,  therefore,  is  most  intense.  The  oesophagus  and  left  bronchus 
are  compressed.  Dysphagia  and  bronchiectasis,  the  latter  causing  bron- 
chorrhoea with  subsequent  gangrene  attended  by  fever,are  likely  to  occur. 
The  cough  in  bronchorrhoea  and  the  fever,  together  with  emaciation, 
simulate  phthisis,  for  which  aneurism  is  often  mistaken.  The  physical 
signs  of  phthisis  are  usually  pronounced  in  this  situation,  and,  with  the 
presence  of  bacilli  in  the  sputum,  render  the  diagnosis  easy.  Rupture 
takes  place  into  the  bronchus  or  into  the  oesophagus.  In  one  of  my 
cases,  which  had  been  treated  for  tuberculosis  because  of  small  liemor- 


5 


448  SPECIAL  DIAGNOSIS. 

rhages,  with  the  conditions  above  mentioned,  death  took  place  from 
rupture  into  the  bronchus,  causing  sudden  profuse  hemorrhage.  When 
the  aneurism  is  adherent  to  the  oesophagus  and  slowly  ulcerating  into 
it  rupture  may  take  place,  followed  by  instantaneous  death.  The  ver- 
tebras may  be  eroded  and  symptoms  of  spinal  compression  arise. 

I  once  saw  an  autopsy  performed  by  a  medico-legal  expert  on  a  case 
of  sudden  death  from  hemorrhage.  The  source  of  the  hemorrhage 
could  not  be  ascertained.  There  was  blood  in  the  stomach.  When  he 
was  about  to  give  up  the  search,  the  oesophagus  and  aorta  were  sug- 
gested for  examination.  A  small  aneurism  was  found  which  had  ulcer- 
ated and  then  ruptured  into  the  gullet.  In  another  the  aneurism  had 
ruptured  into  the  pleural  sac,  causing  internal  concealed  hemor- 
rhage and  death. 

Special  Symptoms.  While  pressure-symptoms  are  the  most  strik- 
ing symptoms  of  this  affection,  pain,  which  is  usually  due  to  pressure, 
must  be  referred  to.  It  is  an  important  constant  symptom.  It  is 
sharp  and  lancinating,  and  may  occur  in  paroxysms.  It  is  more  severe 
and  constant  when  bone  is  eroded  by  pressure  on  the  vertebra?,  or  the 
thorax  in  front.  If  a  bone,  as  the  sternum,  is  perforated,  the  gnaw- 
ing pain  that  attends  the  ulcerative  process  is  relieved.  Anginal 
attacks  may  attend  the  neuralgic  pains  just  described.  Pain  some- 
times follows  the  course  of  the  nerves,  extending  down  the  arm  or  to 
the  neck  or  along  the  course  of  the  intercostal  nerves. 

Cough.  The  cough  is  peculiar.  It  is  paroxysmal  in  many  cases 
and  of  a  brazen,  ringing  character,  indicating  its  laryngeal  origin,  due 
to  pressure  upon  the  recurrent  laryngeal  nerves.  It  is  frequently 
paroxysmal  when  the  pressure  is  directed  upon  the  windpipe  or  bronchus. 
In  the  former  instance  the  cough  is  dry,  in  the  latter  tracheal  and 
bronchial.  It  is  attended  by  a  thin,  watery  expectoration  which,  if 
bronchiectasis  with  fermentation  ensues,  becomes  thick  and  ropy. 
Dyspnoea  occurs  more  frequently  in  aneurism  of  the  transverse  portion 
due  (1)  to  pressure  on  the  recurrent  laryngeal  nerves;  (2)  to  compres- 
sion of  the  trachea;  (3)  to  compression  of  the  left  bronchus.  Marked 
stridor  attends  the  first  form.  When  one  of  the  recurrent  laryngeal 
nerves,  more  particularly  the  left,  is  pressed  upon,  there  is  spasm  or 
paralysis  of  the  muscles  of  the  vocal  cord,  causing  hoarseness  and  loss 
of  voice.  Laryngoscopy  examination  should  not  be  neglected,  for 
paralysis  of  the  abductor  muscles  without  symptoms  may  be  present. 

Hemorrhage.  The  hemorrhage  may  be  gradual  when  there  is  small 
leakage  into  the  trachea  at  the  point  of  compression.  The  amount  of 
blood  lost  is  small.  It  may  take  place  externally  (see  Fig.  75).  Pro- 
fuse hemorrhages,  causing  sudden  death,  occur  in  rupture  into  the 
trachea  or  bronchus,  and  from  perforation  into  the  lung.  With  regard 
to  difficulty  of  deglutition,  it  may  be  said  that  the  sound  should  never 
be  passed  in  suspected  cases  of  aneurism,  on  account  of  the  danger  of 
rupturing  the  sac. 

Clubbed  Finger*.  In  intrathoracic  aneurism  clubbing  of  the  fingers 
and  incurvation  of  the  nails  of  one  hand  are  sometimes  seen,  although 
comparatively  rarely. 

Compression  and  pressure  on  the  sympathetic  system  of  nerves  has 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     449 


been  referred  to.  In  addition  to  pupillary  changes  there  may  be  pallor 
of  one  side  of  the  face.  When  the  pupil  is  dilated  this  pallor  may 
accompany  it  on  account  of  stimulation  of  the  vaso-dilator  fibres. 
When  the  cilio-spinal  branches  of  the  sympathetic  are  pressed  upon, 
the  dilator  fibres  are  paralyzed.  If  the  pupil  contracts,  there  are  also 
hyperemia  of  the  side  of  the  face  and  unilateral  sweating. 

Fig.  93. 


Aneurism  of  ascending  and  transverse  portions  of  aorta  projecting  forward,  destroying  ribs  and 
sternum.  The  skin  ulcerated,  and  gradual  external  leakage  took  place.  The  bleeding  continued 
in  small  amounts  for  a  long  time. 

Physical  Stgns.  Inspection.  In  health  the  position  of  the  aorta 
cannot  be  recognized.  Pulsation  may  be  seen  at  the  episternal  notch 
in  rare  instances,  particularly  in  women,  independently  of  disease  of 
the  aorta ;  it  is  due  to  nervous  palpitation.  An  aneurism  may  exist 
without  any  external  visible  signs.  On  the  other  hand,  pulsation  may 
be  seen  at  either  side  of  the  sternum  above  the  level  of  the  third  rib, 
most  commonly  in  the  second  interspace  on  the  right  side.  The  im- 
pulse may  be  seen  alone  without  visible  swelling  ;  the  chest  must  be 
viewed  from  different  situations  in  order  to  detect  it.  An  oblique  light 
falling  on  the  surface  is  sometimes  necessary.  When  the  innominate 
artery  is  involved  the  pul.-ation  is  observed  in  the  neck,  above  the 
sterno- clavicular  junction,  or  above  the  sternum. 

With  the  abnormal  impulse  a  swelling  or  tumor  is  often  present.  It 
may  be  large  enough  to  press  the  upper  portion  of  the  sternum  and  ad- 
jacent ribs  forward.  In  other  instances  a  tumor  the  size  of  the  half  of 
a.  lemon  may  be  seen  along  the  edge  of  the  sternum.  The  most  frequent 
site  is  the  first  and  second  right,  or  the  second  left  interspace.  The 
skin  over  the  tumor,  as  in  the  case  of  which  an  illustration  is  given, 
may  ulcerate  and  be  the  seat  of  persistent  small  hemorrhages.  The 
apex-beat  of  the  heart  is  displaced  downward  and  outward  from  pressure. 

29 


450 


SPECIAL  DIAGNOSIS. 


If  the  aneurism  is  seated  in  the  ascending  portion  of  the  aorta,  just 
beyond  the  aortic  ring,  a  pulsating  tumor  may  he  seen  in  the  third 
interspace  at  the  left  edge  of  the  steruum.  If  in  the  ascending  por- 
tion, beyond  the  heart,  the  tumor  is  in  the  first  or  second  interspace 
along  the  right  edge  of  the  sternum.  If  the  aneurism  is  in  the  trans- 
verse portion  of  the  aorta,  the  upper  portion  of  the  sternum  is  fre- 
quently made  to  protrude,  or  the  tumor  projects  upward  into  the  fossae 
of  the  neck.  If  in  the  descending  portion,  it  is  in  the  second  or  third 
interspace  on  the  left  side.  In  this  portion  of  the  aorta  a  tumor  is 
seen  in  the  left  scapular  region  in  rare  instances. 

Palpation.  Palpation  must  be  employed  by  the  usual  method  ; 
bimanual  palpation  must  also  be  used,  one  hand  placed  upon  the  ster- 
num and  the  other  upon  the  vertebrae.  Moderate  pressure  should  be 
exerted.  Palpation  should  also  be  employed  at  different  periods  of 
respiration.  At  times  signs  are  only  yielded  at  the  end  of  complete 
expiration.  It  must  further  be  said  that  palpation  must  be  employed 
both  with  the  tips  of  the  fingers  and  with  the  palm  of  the  hand  applied 
to  the  surface. 


Fig.' 94. 


Possible  position  of  impulse  in.  aneurism  ;  arranged  in  order  of  frequency. 

By  palpation  the  area  and  degree  of  pulsation  are  determined.  If 
the  aneurism  is  large  or  has  perforated,  the  impulse  is  expansile  and 
heaving  in  character.  The  sac  may  be  soft  and  fluctuating,  but  usually 
presents  considerable  resistance.  In  addition  to  the  systolic  impulse  the 
diastolic  shock  is  also  felt.  This  is  the  most  conclusive  physical  sign. 
A  thrill  is  frequently  present,  systolic  in  time,  usually  due~to  dilatation 
of  the  arch;  at  times,  to  sacculated  aneurism.  Without  visible  tumor, 
pulsation  and  thrill  may  be  felt  in  the  suprasternal  notch,  if  the  head 
is  bent  forward  so  that  the  tissues  are  relaxed,  and  the  fingers  pushed 
down  toward  the  aorta.  When  the  aneurism  is  filled  or  filling  with 
clot,  the  tumor  may  be  seen  and  felt,  but  no  impulse  will  be  trans- 
mitted to  the  hand  or  thrill  felt  by  the  fingers. 

Percussion.  Percussion  furnishes  the  most  reliable  evidence  of  the 
presence  of  an  aneurism  or  aneurismal  dilatation  in  cases  in  which 
the  tumor  is  not  too  deep-seated  or  small  in  size  (sec  Cardiac  Percus- 


DISEASES  OF  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     451 

sion).  The  area  of  dulness  is  increased  somewhere  in  the  course  of 
the  aorta.  It  may  be  observed  projecting  outward  at  the  right  edge 
of  the  sternum  when  the  ascending  portion  of  the  aorta  is  the  seat  of 
disease,  or  over  the  entire  upper  part  of  the  sternum,  extending  toward 
the  left,  when  the  transverse  portion  is  diseased.  It  may  be  observed  as 
an  extension  of  cardiac  dulness  upward  in  the  second  and  third  inter- 
spaces. Sometimes  dulness  is  detected  in  the  scapular  regions,  particu- 
larly of  the  left  side.  The  percussion-tone  is  flat,  and  there  is  marked 
sense  of  resistance.  Percussion  must  be  employed  with  the  patient  in 
the  upright  and  in  the  recumbent  posture.  The  character  of  the  tone 
and  the  shape  of  the  dulness  must  be  noted  at  the  end  of  full  inspira- 
tion and  of  full  expiration. 

Auscultatory  percussion  is  of  the  utmost  value,  and  the  method  of 
percussion  taught  by  Sansom  and  Ewart  must  be  carefully  followed. 
An  aneurismal  tumor  may  be  present  without  thrill  or  murmur,  but 
yields  signs  of  dulness  on  percussion. 

Auscultation.  As  just  stated,  murmurs  may  not  always  be  present. 
They  depend  upon  the  amount  of  fibrin  in  the  sac.  When  present  the 
murmur  is  systolic  in  time,  heard  with  maximum  intensity  usually  over 
the  abnormal  area  of  impulse  or  tumor,  or  over  the  increasing  area  of 
dulness.  It  is  transmitted  in  the  direction  of  the  vessels  and  may  be 
heard  loud  in  the  vessels  of  the  neck  and  along  the  course  of  the  aorta. 
Often  a  double  murmur  is  heard,  the  diastolic  sound  being  due  to  asso- 
ciated regurgitation  at  the  aortic  orifice.      The  diastolic  murmur  alone 

.  ...  . 

may  sometimes  be  heard.      Increase  in  intensity  or  accentuation  of  the 

aortic  second  sound  is  pronounced.  The  sound  is  ringing  in  character 
and  is  rarely  absent  in  large  aneurisms. 

The  Peripheral  Vessels  in  Aneurism.  The  pulse  in  the  two  radial 
arteries  may  show  a  marked  difference  both  in  volume  and  in  time. 
The  difference  may  indicate  the  position  of  the  aneurism.  If  the  pulse 
of  the  right  radial  is  smaller  than  the  left,  the  aneurism  may  be  in  or 
near  the  innominate  artery;  if  the  opposite,  it  is  near  or  includes  the 
orifice  of  the  left  subclavian.  In  the  same  way  the  difference  in  time 
may  also  aid  in  determining  the  location.  Osier  refers  to  obliteration 
of  the  pulse  in  the  abdominal  aorta  and  its  branches.  In  one  case  he 
could  not  feel  throbbing  in  the  aorta  and  the  femorals,  although  the 
circulation  was  unimpaired.  The  aneurism  was  in  the  descending  por- 
tion of  the  aorta,  and  its  pulsation  was  seen  in  the  left  scapular  region. 
The  sac  was  sufficiently  large  to  act  as  a  reservoir,  which  filled  during 
the  ventricular  systole,  and  from  which  the  blood  poured  toward  the 
periphery  in  a  continuous  stream  instead  of  being  intermittent. 

Tracheal  Tugging.  Tracheal  tugging  may  be  obtained  in  one  of 
two  ways.  By  the  old  method  the  patient  should  be  sitting  or  stand- 
ing, while  the  observer  sits  or  stands  to  one  side,  and  faces  him.  With 
hand  furthest  from  the  patient  steadying  the  head,  the  observer  gently 
but  firmly  grasps  the  outer  and  under  surface  of  the  cricoid  cartilage 
with  the  thumb  and  finger  of  the  other  hand,  while  the  head  is  slightly 
thrown  hack.  The  head  is  then  flexed  so  that  the  neck  is  no  longer 
stretched.  The  patient  is  then  told  to  hold  his  breath  completely,  and 
any  up-and-down  movement  of  the  trachea  is  immediately  transmitted 


452  SPECIAL  DIAGNOSIS. 

to  the  observer's  fingers.  One  must  not  mistake  the  transmitted  pul- 
sation in  the  cervical  vessels  for  such  movement;  and  great  care  should 
be  exercised  to  see  that  the  breathing  is  entirely  stopped. 

In  the  other,  or  new  method,  as  proposed  and  practised  by  Ewart 
(British  Medical  Journal,  March  19,  1892),  the  observer  stands  behind 
the  patient,  steadying  the  latter' s  head  against  his  body,  and  the  cricoid 
is  firmly  held  between  the  tips  of  the  first  or  middle  fingers.  The 
writer,  after  considerable  experience,  prefers  this  second  method,  on 
account  of  delicacy  of  touch,  firmness  of  grasp,  and  comfort  to  the 
patient. 

Diagnosis  of  Aneurism.  The  special  points  for  diagnosis  are  :  the 
setiological  factors  ;  the  antecedent  pathological  conditions,  as  arterial 
sclerosis  ;  the  occurrence  of  pain  ;  the  occurrence  of  pressure-symp- 
toms ;  and  the  physical  signs.  These  have  been  sufficiently  dwelt 
upon  and  it  is  not  necessary  to  consider  them  again.  It  must  not  be 
forgotten  that  aneurism  may  be  present  without  diagnostic  physical 
signs,  and,  on  the  other  hand,  the  pressure-symptoms  may  also  be  in 
abeyance.  If  one  of  the  two  is  present  in  the  male  subject  past  forty, 
with  a  previous  history  of  syphilis,  gont,  alcoholism,  or  muscular  strain, 
the  probability  is  that  an  aneurism  exists.  The  pressure-symptoms 
always  point  to  some  form  of  intrathoracic  disease  as  the  cause  of  this 
group  of  symptoms.  Thus,  in  cancerous  disease  of  the  lymphatic 
glands,  or  other  tumors  within  the  mediastinum,  pressure -symptoms 
exactly  simulating  aneurism  may  be  present  and  also  the  physical  s-igns 
of  a  tumor.  The  tumor,  however,  rarely  projects  externally,  and  still 
more  rarely  pulsates.  If  pulsation  is  present,  it  is  not  of  the  expansile 
character  seen  in  aneurism,  nor  is  there  as  decided  a  systolic  shock 
when  the  ear  is  held  against  the  chest.  By  the  same  method  we  observe 
the  shock  of  the  heart-sounds,  which  are  notably  lessened  or  absent  in 
tumors  from  other  causes  than  aneurism.  In  deep-seated  tumors  with 
pressure-symptoms  the  condition  of  the  arteries,  apart  from  aneurism, 
is  of  diagnostic  importance.  Accentuation  of  the  aortic  second  sound, 
with  hypertrophy  of  the  heart,  points  to  aneurism.  The  presence  of 
tracheal  tugging  is  also  a  valuable  diagnostic  point  in  its  favor.  In 
tumor,  and  especially  in  cancer,  there  are  emaciation  and  development 
of  a  cachexia,  which  is,  as  is  well  known,  most  pronounced  in  cancer 
of  the  oesophagus.  Cancer  of  the  oesophagus,  from  its  frequent  point 
of  election  near  the  left  bronchus,  often  simulates  the  pressure-symp- 
toms of  aneurism. 

Aneurism  must  be  distinguished  from  the  pulsation  of  the  aorta 
which  is  seen  in  aortic  regurgitation.  This  pulsation  is  usually  associ- 
ated with  dilatation,  the  latter  causing  increased  dulness,  which  may 
add  further  to  the  confusion.  Exaggerated  pulsation  without  dilatation 
may,  as  B  ram  well  has  recorded,  be  the  cause  of  dulness  and  pulsation 
over  the  aorta.  The  subjects  are  under  forty,  neurotic,  and  usually 
an9emic. 

It  is  not,  as  a  rule,  difficult  to  distinguish  between  pulsating  empy- 
ema and  aneurism.  Wilson  points  out  that  aneurism  bears  a  definite 
relation  to  the  central  long  axis  of  the  chest.  The  area  of  dulness  of 
aneurism  is  circumscribed,  and  is  usually  the  seat  of  murmurs  or  other 


DISEASES  OE  HEART,  BLOODVESSELS,  AND  MEDIASTINUM.     453 

.sounds  synchronous  with  the  rhythm  of  the  heart.  The  signs  of  pul- 
sating empyema  are  usually  upon  the  left  side  and  at  a  distance  from 
the  median  line.  The  percussion-duluess  is  at  the  base  of  the  chest 
and  quite  extensive.  Arterial  murmurs  are  not  present.  The  pulsation 
is  influenced  by  pressure  and  by  respiratory  movements. 

In  mediastinal  cancer  we  are  aided  by  the  discovery  of  enlargement 
of  the  glands  in  the  axillary  or  some  other  situation,  or  by  a  history 
of  the  growth  elsewhere. 

Aneurism  must  not  be  confounded  with  phthisis.  The  diseased 
vessel  may  occlude  a  bronchus  and  cause  collapse  and  bronchial  dilata- 
tion ;  hemorrhage  may  occur;  bronchorrhoea  and  cough  always  ensue. 
Fever  is  not  marked,  which  fact,  with  tracheal  tugging,  vascular  phys- 
ical signs,  and  the  absence  of  tubercle  bacilli,  points  to  aneurism. 

Diseases  of  the  Mediastinum. 

Inflammation  of  the  mediastinum  may  be  limited  to  the  glands  or 
the  connective  tissue.  Moderate  inflammation  of  the  glands,  lymph- 
adenitis, occurs  in  bronchitis  and  pneumonia,  particularly  if  brouchitis 
is  of  specific  origin,  as  in  measles  or  influenza.  It  is  said  that  such 
inflammation  is  of  common  occurrence  in  whooping-cough,  and  may 
be  the  exciting  cause  of  the  paroxysms.  DeMussv  and  Guiteras  have 
found  physical  signs  of  enlargement,  characterized  by  dulness  in  the 
upper  part  of  the  interscapular  region,  in  cases  of  this  disease  and  of 
influenza.  Other  authorities,  as  Osier,  dispute  the  possibility  of  this 
occurrence,  or  at  of  least  of  its  recognition  by  physical  signs.  Tubercu- 
lous inflammation  of  the  lymphatic  glands  of  the  mediastinum  may 
give  rise,  however,  to  local  physical  signs.  Abscess  of  the  glands 
cannot  be  distinguished  during  life. 

Tumors  of  the  Mediastinum.  Cancer  and  sarcoma  are  the  most  fre- 
quent forms  of  tumor  in  this  locality.  Hare  found  the  proportion  in 
520  cases  to  be  as  follows  :  134  of  cancer,  98  of  sarcoma,  21  of  lymph- 
oma, 7  of  fibroma,  11  of  dermoid  cyst,  8  of  hydatid  cyst,  and  the 
remainder  of  lipoma,  gumma,  and  enchondroma.  With  the  applica- 
tion of  more  correct  histological  methods  we  now  know  that  sarcoma 
is  more  common  than  carcinoma.  The  tumor  is  most  frequently  found 
in  the  anterior  mediastinum  when  one  region  alone  is  affected.  The 
disease  may  be  either  primary  or  secondary.  In  sarcoma  it  is  usually 
primary.  Males  are  chiefly  affected,  and  most  often  between  thirty 
and  forty.  The  thymus  gland,  the  lymphatic  glands,  the  pleura,  or 
the  oesophagus  is  the  source  of  origin  in  all  cases,  the  former  the  most 
frequent. 

The  symptoms  of  mediastinal  tumor  are  chiefly  due  to  pressure. 
Dyspnoea  is  early  and  constant,  and  maybe  laryngeal,  or  tracheal  from 
pressure  on  the  trachea.  In  some  instances  encroachment  upon  the 
heart  or  the  vessels  causes  dyspnoea.  Again,  the  dyspnoea  may  be  due 
to  a  pleural  effusion  which  accompanies  the  growths.  Cough  of  a  pecu- 
liar character  occurs.  It  is  laryngeal,  and  of  a  dry,  brazen  quality. 
Aphonia  may  arise  from  pressure  upon  the  recurrent  laryngeal  nerves 
(see  Disease  of  the  Larynx).     If  the  bloodvessels  are  pressed  upon, 


454  SPECIAL  DIAGNOSIS. 

symptoms  of  obstruction  occur  depending  upon  the  vessel  occluded. 
(Edema  of  the  upper  extremities  may  occur.  If  the  oesophagus  is 
pressed  upon,  there  is  difficulty  in  deglutition.  In  some  instances  the 
sympathetic  nerve  is  pressed  upon,  causing  hyperemias  and  pupillary 
changes. 

The  physical  signs  are  those  of  a  tumor  in  the  anterior  portion  of 
the  chest,  frequently  in  the  precordial  area,  which  may  or  may  not 
pulsate ;  dislocation  of  the  heart,  not  limited  to  any  position  ;  great 
dulness  and  resistance ;  frequently  conduction  of  lung-  and  heart- 
sounds  to  some  distance ;  at  times  a  systolic  murmur ;  increased  size 
and  pulsation  of  the  veins  ;  physical  signs  from  pressure  (see  Aneu- 
rism). It  must  be  remembered  that  pain  is  more  common  in  aneu- 
rism, fever  and  emaciation  in  mediastinal  growths. 

Tumors  of  the  anterior  mediastinum  present  the  physical  signs,  in 
front,  of  a  prominence  more  or  less  marked,  often  including  projection 
of  the  sternum ;  an  irregular  area  of  dulness  ;  rarely  transmitted 
pulsation  ;  more  frequently  transmitted  heart-  and  lung-sounds.  It  is 
the  form  in  which  the  phenomena  of  pressure  upon  the  veins  are  most 
marked.  Symptoms  from  arterial  pressure  (difference  in  pulse),  pres- 
sure on  the  vagus  and  sympathetic  are  less  frequent.  Dyspnoea  may 
occur. 

Tumors  of  the  middle  and  posterior  mediastinum  are  characterized  by 
pressure  upon  structures  adjacent  to  the  bronchi,  hence  we  have  symp- 
toms from  pressure  upon  the  bronchi,  oesophagus,  aorta,  and  the  nerves. 
Dyspnoea  and  cough  are  the  most  pronounced  symptoms,  while  phe- 
nomena from  pressure  on  the  vagus,  cardiac  palpitation,  vomiting,  etc., 
are  not  uncommon.  Emaciation  and  a  cachexia  are  more  marked 
than  in  tumors  in  other  regions.  Pepper  and  Stengel  consider  that 
fever  attends  growths  in  this  region  with  greater  frequency. 

Tumors  of  pleural  origin  have  symptoms  of  acute  or  subacute  pleu- 
ritis,  with  or  without  effusion.  The  fluid  secured  by  puncture  is 
usually  bloody,  rarely  chylous,  and  may  contain  suspicious  vacuolated 
epithelial  cells.  A  mass  may  be  suspected  if  there  is  great  resistance 
to  the  trocar.  If  the  tumor  ulcerate  into  the  lung,  the  sputa  may  con- 
tain characteristic  groups  of  cells,  while  hemorrhagic  oozing  may  be 
suspicious. 


CHAPTER    IV. 

DISEASES   OF   THE   MOUTH,   FAUCES,   PHARYNX,   AND 
(ESOPHAGUS. 

The  Mouth. 

The  mouth  is  affected  by  comparatively  few  diseases  and  most  of 
these  are  the  result  of  infection  or  of  trauma,  or,  rarely,  are  tropho- 
neurotic. The  cavity  forms  a  good  breeding-place  for  all  forms  of 
organisms,  and  were  it  not  for  the  secretions  and  coustant  cleansing  of 
the  mouth  by  the  passage  of  food  and  its  physiological  labors,  diseases 
would  be  very  common.  Indeed,  it  is  possible  that  such  diseases  do 
not  take  place  at  all  unless  there  is  such  perversion  of  the  normal  secre- 
tion as  destroys  its  antiseptic  or  antimicrobic  power.  We  know  but 
little  specifically  concerning  the  changes  in  the  secretions.  Clinically 
we  do  know,  however,  that  in  conditions  of  poor  nutrition,  in  wasting 
diseases  generally,  and  probably  in  connection  with  the  rheumatic 
diathesis,  there  is  such  change  in  the  secretions  as  permits  pathogenic 
micro-organisms  to  exercise  their  influence  upon  the  mucous  mem- 
brane. The  result  of  their  action  is  seen  in  various  forms  of  inflam- 
mation . 

Symptomatology.  The  symptomatology  of  mouth-affections  is  the 
symptomatology  of  inflammation  :  pain,  heat,  redness,  and  swelling. 

The  Subjective  Symptoms. 

The  subjective  symptoms  are  not  characterized  by  great  gravity,  but 
they  are  most  annoying. 

Pain.  This  symptom  is  most  aggravating  because  it  is  excited  by 
the  many  functional  acts  connected  with  the  mouth.  It  occurs  in  all 
inflammations  and  ulcerations  except  those  due  to  syphilis.  It  is  aggra- 
vated by  food,  by  movements  of  the  lips,  cheeks,  or  tongue,  and  by 
attempts  to  discharge  saliva.  The  absence  of  pain  is  observed  in 
gangrene. 

Heat.   The  patient  complains  of  heat  of  the  mouth  in  inflammations. 

Dryness.  This  symptom  is  complained  of  in  fevers,  ancl  by  those 
who  are  compelled  to  sleep  with  the  mouth  open.  It  may  be  a  condi- 
tion of  itself,  as  the  following  shows: 

Dry  Mouth.  Xerastoma.  Hutchinson  first  described  a  condition  of 
the  mouth  in  which  dryness  was  the  chief  complaint.  The  secretions 
are  suppressed  entirely,  the  tongue  red  and  dry,  the  mucous  membrane 
of  the  cheeks  and  palate  smooth,  shining,  and  dry.  Functional  move- 
ments are  very  difficult.  The  majority  of  the  cases  are  in  women  in 
whom  the  general  health  is  always  impaired.  Hayden  thinks  that 
the  secretion  of  the  salivary  and  buccal  glands  is  modified  as  the  result 


456  SPECIAL  DIAGNOSIS. 

of  a  central  nervous  disturbance.  In  xerostoma  there  is  also  dryness 
of  the  nostrils  and  eyes,  with  intolerable  itching.  There  is  also  some 
dryness  of  the  mouth  in  fevers.  It  is  also  symptomatic  of  chronic 
gastritis,  and  may  occur  in  diabetes. 

The  Objective  Symptoms. 

The  objective  symptoms  are  determined  by  inspection  and  palpation. 
By  these  means  we  observe  the  color  of  the  parts  of  the  mouth,  changes 
in  temperature,  as  well  as  in  the  size  and  shape  (swelling).  The  teeth, 
gums,  and  tongue  are  also  examined. 

Color.  The  normal  redness  of  the  mucous  membrane  may  be 
increased  or  diminished  in  intensity.  Pallor  is  associated  with  anaemia. 
Increased  redness  attends  inflammation,  and  with  it  the  temperature  is 
raised.  The  mucous  membrane  is  yellow  in  jaundice,  bluish  in  cya- 
nosis. Both  of  the  latter  changes  are  observed  to  greater  advantage 
under  the  tongue.  The  mucous  membrane  is  the  seat  of  pigmentation 
in  Addison's  disease  and  in  argyria.  In  the  former,  small  oval  pur- 
plish spots  are  seen.  They  must  not  be  confounded  with  the  pigmented 
spots  common  after  stomatitis  in  negroes.  Eruptions  occur  in  the 
mouth  and  may  precede  external  eruptions.  This  is  notably  so  in 
measles.  In  this  affection  the  eruption  is  seen  on  the  hard  and  soft 
palate  twenty-four  hours  before  the  development  of  the  rash.  In 
smallpox  and  chicken  pox  the  vesicles  are  seen. 

Shape.  Swellings  are  seen  usually  as  the  result  of  disease  of  struc- 
tures about  the  mouth.  The  floor  of  the  mouth  is  encroached  upon  by 
glands  underneath,  or  by  swelling  of  the  cellular  tissue.  Bone  diseases 
and  some  teeth  affections  cause  swellings  The  dental  arch  must  be 
observed.  Increase  in  height  of  the  arch  is  due  to  adenoid  disease  or 
to  the  habit  of  thumb-sucking  in  childhood,  much  more  likely  the 
former. 

Fcetor.  The  odor  imparted  to  exhaled  air  is  peculiar  in  mouth- 
affections.  It  may  be  a  simple  fcetor  or  of  a  metallic  or  gangrenous 
odor.  Fcetor  attends  all  inflammations  ;  it  is  more  pronounced  in 
ulcerative  and  mercurial  stomatitis.     In  the  latter  it  may  be  metallic. 

Hemorrhage.  Petechia  in  purpura  hemorrhagica ;  submucous 
hemorrhages  in  scorbutus  and  severe  forms  of  purpura — morbus 
maculosus  werlhofi — are  common  on  the  cheeks  and  on  the  gums.  In 
ulcerative  endocarditis  hemorrhage  infarcts  are  seen.  In  grave  anae- 
mias petechia  are  also  seen. 

Capillary  oozing  of  blood  takes  place  from  the  mucous  membranes 
in  low  typhoid  states.  The  accumulated  blood  collects  about  the 
teeth,  on  the  tongue,  etc.,  and  in  febrile  states  becomes  dry.  Dry  in- 
crustations are  known  as  sordes. 

Salivation.  Increased  flow  of  saliva  occurs  in  all  inflammations 
unless  attended  by  high  fever.  It  may  be  constantly  discharged  by 
the  patient  or  dribble  in  a  continuous  stream  (see  Saliva). 

Secretions  of  the  Mouth.  The  saliva  is  derived  from  the  par- 
otid, submaxillary  and  sublingual  glands,  and  from  the  mucous  glands 
within  the  mouth.     The  mouth  should  be  washed  with  warm  alkaline 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  CESOPHAGUS.    457 

solution  and  afterward  with  cold  water,  in  order  that  the  saliva  obtained 
may  be  perfectly  pure  for  examination.  After  the  washing  the  glands 
may  be  stimulated  by  the  application  of  dilute  acid  on  a  glass  rod. 
The  normal  amount  secreted  in  twenty-four  hours  varies  from  two 
to  three  pints.  It  is  of  a  light  bluish  color,  or  colorless.  It  is  some- 
what stringy.  On  standing,  two  layers  form  in  a  conical  glass,  the 
upper  clear,  the  lower  cloudy.     The  reaction  of  saliva  is  alkaline. 

3Iicroscopio  Examination.  The  following  formed  elements  are  ob- 
served :  1.  Salivary  corpuscles  of  the  appearance  of,  but  larger  and 
more  granular  than,  a  white  corpuscle.  2„  Epithelium.  The  squa- 
mous variety  derived  from  the  mouth  is  seen.  The  cells  are  large  in 
size  and  of  polygonal  shape.  3.  Fuugi.  In  health  the  mould  aud 
yeast  fungi  are  seldom  found.  In  disease  they  are  present  in  large 
numbers  ;  fission-fungi  are  met  with  in  great  numbers,  both  in  health 
and  in  disease.  In  health  small  and  large  colonies  of  micrococci  are 
found  along  with  abundant  bacilli  Miller  has  studied  the  micro- 
organisms of  the  mouth  carefully  and  exhaustively  (see  The  Dental 
Cosmos),  both  by  microscopical  examination  and  culture-methods. 
The  following  are  found  to  be  pathogenetic  :  (1)  The  leptothrix  buc- 
calis ;  (2)  vibrio  buccalis  ;  (3)  spirochete  dentium  ;  (4)  micrococcus 
tetragenes  ;  (5)  the  micrococcus  de  la  rage  ;  (6)  the  micrococcus  of  sep- 
ticemic sputa  ;  (7)  the  bacillus  of  decaying  teeth,  three  varieties  of 
the  staphylococcus  ;  (8)  the  bacillus  crassus  sputigenus  ;  (9)  the  bacil- 
lus salivarius  septicus  and  bacillus  septicus  sputigenus. 


Fio.  95. 


Buccal  secretion.  (Eye-piece  III.,  obj.  Reichert,  1/15,  homogeneous  immersion  ;  Abbe  illumina- 
tion, open  condenser.)    Friedlander's  and  Giinther's  method.    (Von  Jaksch.) 

a,  epithelial  cells;  b,  salivary  corpuscles;  c,  fat-drops;  d,  leucocytes;  e,  spirochete  buccalis  ; 
/,  common  bacilli  of  mouth  ;  g,  leptothrix  buccalis  ;  h,  i,  k.  different  fungi. 


Of  course  in  the  saliva  the  thrush-fungus,  aetinomyees,  the  tubercle 
bacillus,  and  the  bacillus  of  diphtheria  are  found.  It  must  not  be 
forgotten  that  the  diplococcus  pneumoniae  or  micrococcus  lanceolatus, 
which  is  the  specific  cause  of  pneumonia,  is  found  in  the  saliva  of  some 
persons  in  health.      It  is  also  called  the  bacillus  sputi  septiesemici. 

Chemical  Examination.  The  chemical  characters  of  the  secretion 
depend  upon  the  activity  of  the  different  glands.      The  saliva  contains 


458 


SPECIAL  DIAGNOSIS. 


a  trace  of  albumin,  found  by  heating  ;  a  ferment  which  changes  starch 
into  sugar  ;  mucin  ;  and  occasioually  sulphocyanide  of  potassium.  In 
disease,  as  the  quantity  is  diminished  rather  than  increased,  examina- 
tions have  rarely  been  made.  In  ptyalism  the  saliva  should  be  collected 
after  rinsing  the  mouth  frequently,  especially  after  eating.  The  reac- 
tion is  found  to  be  alkaline,  and  the  specific  gravity  low,  1002  to  1006. 
Albumin  is  tested  for  by  the  usual  methods.  The  sulphocyanides  are 
detected  by  a  solution  of  chloride  of  iron.  When  this  is  added  to  the 
fluid  a  bright  red  color  appears  which  does  not  disappear  with  heat ;  a 
similar  color,  due  to  the  precipitation  of  meconic  acid,  may  be  obtained 
by  the  same  test  from  the  saliva  in  opium-poisoning. 

Sugar  is  tested  for  by  the  methods  used  in  the  examination  of  the 
blood.  The  diastatic  ferment  is  detected  by  adding  5  com.  of  saliva 
to  50  com.  of  starch  solution  and  placing  the  mixture  in  a  warm  cham- 
ber or  a  water-bath  heated  to  40°  C.  After  an  hour's  time  the  fluid 
will  show  the  presence  of  grape-sugar.  Nitrites  are  detected  by  add- 
ing a  little  saliva  to  a  mixture  of  starch  paste,  iodide  of  potassium, 
and  dilute  sulphuric  acid.  If  the  nitrites  are  present,  a  blue  color 
results. 

Saliva  in  Disease.  In  catarrhal  stomatitis  the  secretion  is  increased. 
It  is  acid  and  contains  epithelium  in  excess.  In  ulcerative  stomatitis 
it  is  also  increased,  is  of  a  dark-brown  color,  fnetid,  and  alkaline.  It 
contains  degenerated  epithelium,  leucocytes,  blood-corpuscles,  and  many 
forms  of  fungi.  It  is  increased  in  pregnancy,  in  rabies,  and  in  glosso- 
labio-laryngeal  palsy.  I  have  seen  it  in  excess  in  the  convalescence  of 
typhoid  fever.      It  is  increased  by  the  internal  use  of  jaborandi. 


Fig.  96. 


O'idium  albicans,  the  vegetable  parasite  of  muguet  or  thrush.    (Reduced  from  Ch.  Robin.) 

The  reaction  becomes  acid  in  diabetes,  gout,  rheumatism,  and  mer- 
curial poisoning.  Urea  may  be  found  in  cases  of  nephritis,  particu- 
larly in  ursemia.  There  is  no  sugar  in  diabetes.  Fenwick  has 
investigated  the  changes  in  the  sulphocyanide  of  potassium  in  disease. 
By  a  scale  of  colors  he  was  enabled  to  compare  the  saliva  in  which 
sulphocyanide  of  potassium  had  been  detected  in  health  with  the 
saliva  in  various  diseases.  He  believes  that  the  amount  of  this  ingre- 
dient is  indicative  of  the  degree  of  functional  activity  of  the  organs 
of  nutrition.      It  is  increased  in  acute  inflammation  and  in  the  earlier 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     459 

stages  of  cancer  and  phthisis  ;  in  acute  congestion  of  the  liver  from 
stimulants  or  food  excess  ;  and  in  rheumatism,  gout,  and  the  conva- 
lescence of  typhoid  fever.  Where  the  power  of  the  nutritive  organs 
is  diminished  the  sulphocyanide  of  potassium  is  lessened,  as  in  late 
phthisis  and  cancer,  the  later  stages  of  chronic  diarrhoea  and  dysen- 
tery, chronic  catarrhal  jaundice,  in  ascites,  and  in  the  passive  con- 
gestion of  the  abdominal  viscera.  Fenwick  believes  that  tedious 
recovery  and  frequent  relapses  will  occur  if  this  element  is  found  in 
excess  in  acute  rheumatism. 

Thrush.  The  fungus  peculiar  to  this  disease  is  found.  Saliva  is 
increased  ;  it  is  usually  acid.  The  disease  is  characterized  by  the  for- 
mation of  small  patches  on  the  mucous  membrane,  which  in  a  few 
days  coalesce  and  form  a  mass  which  may  cover  the  entire  mouth  and 
extend  to  the  fauces.  Before  coalescing  they  are  firmly  adherent. 
Subsequently  they  loosen.  On  microscopical  examination,  in  addition 
to  epithelial  cells,  leucocytes,  and  unorganized  elements,  the  charac- 
teristic parasite  is  seen.  It  is  of  ribbon-shape,  varying  in  length,  and 
composed  of  long  segments  which  often  contain  highly  refractive 
nuclei  at  either  end.  The  segments  are  homogeneous  ;  they  vary  in 
length,  those  nearest  the  extremities  being  somewhat  shorter.  When 
mounted  in  glycerin  they  are  readily  seen.     Spores  are  also  seen. 

The  Leptothrix  Buccalis.  The  latter  is  seen  in  ribbon-like  bundles 
composed  of  various  segments  ;  it  stains  a  bluish-red  in  potassic  iodide 
solution.     It  is  most  frequently  seen  in  the  tartar  of  the  teeth. 

Fig.  97. 


/ 
m 


kiii^ 


:# 


Leptothrix  buccalis  from  the  gums  at  edges  of  teeth,     x  350. 
a,  the  filaments  separated  ;   6,  masses  of  filaments. 

The  Gums.  The  colo.r  and  consistence  are  examined.  The  former 
changes  with  changes  in  the  mucous  membrane  of  the  mouth,  in  inflam- 
mations and  ulcerations,  and  in  certain  metallic  poisonings.  The  gums 
swell  and  grow  spongy  in  inflammations. 

The  Gingival  Line.  In  cases  of  tuberculosis  a  red-line  at  the  junc- 
tion of  the  gums  and  the  teeth  is  frequently  seen.  At  one  time  it  was 
thought  to  be  of  diagnostic  value.  It  is  seen,  however,  in  other 
cachectic  conditions,  as  carcinoma,  and  at  times  in  diabetes. 

The  Gums  in  Scurvy.     In  scurvy  the  gums  are  swollen  and  spongy. 


460  SPECIAL  DIAGNOSIS. 

They  bleed  easily,  and  are  usually  streaked  with  blood.  Ulcers  form 
along  the  margin  of  the  teeth.  There  is  not  much  foetor  of  the  breath. 
In  mild  cases  the  inflammation  may  be  limited  to  the  gums  of  four  or 
five  teeth.  The  gums  of  decayed  teeth  are  usually  the  seat  of  the 
most  marked  inflammation.  Infants  may  have  scurvy  as  well  as  adults 
— especially  if  fed  exclusively  on  sterilized  milk  or  malt  preparations. 

The  Gums  in  Lead-poisoning.  In  chronic  lead-poisoning  a  blue-line 
appears  on  the  gums  and  margins  of  the  teeth.  The  line  is  preceded 
by  a  row  of  separate  black  dots  occupying  the  seat  of  the  papillae  of 
the  mucous  membrane.  It  does  not  always  extend  along  the  entire 
margin,  but  may  be  limited  to  a  few  front  teeth  in  either  the  upper 
or  lower  jaw.  In  the  more  advanced  cases  there  is  some  salivation  and 
sweetish  metallic  taste  in  the  mouth  and  metallic  foetor  of  the  breath. 

The  Teeth.  In  all  diseases  of  the  gastro-intestinal  tract  it  is  im- 
portant to  investigate  the  state  of  the  teeth.  Cases  of  indigestion  are 
often  due  to  defective  mastication  rendered  so  by  decayed  teeth.  Per- 
sistent aural,  nasal,  and  ophthalmic  affections  may  have  their  primary 
origin  in  disease  of  the  teeth.  Caries  of  the  teeth  may  cause  head- 
aches or  neuralgias,  near  or  remote  (see  Headache),  and  may  explain 
many  cases  of  foul  breath.  Pitting  of  the  surface  of  the  teeth  and 
thinning  of  the  enamel  in  transverse  grooves  are  held  by  some  to  be 
due  to  mercury.  There  is  no  doubt  that  infantile  stomatitis,  inde- 
pendent of  mercury,  is  the  cause  of  these  changes.  They  must  be 
distinguished  from  the  so-called  Hutchinson's  teeth.  In  stomatitis  the 
molars  are  honeycombed  to  the  greatest  degree,  the  incisors  becoming 
affected  next.  In  addition  to  pitting  and  erosion  the  color  may  be 
darker.     A  transverse  furrow  crosses  all  the  teeth  at  the  same  level. 

The  Teeth  in  Gout.  Erosion  of  the  teeth  takes  place  in  gouty  sub- 
jects. There  are  wasting  and  loss  of  polish  of  the  labial  surface  fol- 
lowed by  deep  grooves  which  extend  into  the  body  of  the  teeth. 
Pyorrhoea  alveolaris  is  another  expression  of  gout.  There  is,  first, 
usually  a  marginal  inflammation  of  the  gums  ;  second,  inflammation 
and  necrosis  of  the  pericementum ;  third,  loosening  of  the  teeth  and 
the  formation  of  so-called  calculi. 

The  Teeth  of  Congenital  Syphilis.  The  upper  central  incisors  of  the 
permanent  set  are  affected.     They  are  dwarfed,  narrowed,  and  short. 

Fig.  98. 


Notched  teeth.    Malformation  of  permanent  teeth  found  in  hereditary  syphilis. 
(Mr.  Jonathan  Hutchinson.) 

The  middle  lobe  of  the  tooth  is  so  atrophied  as  to  leave  a  single 
broad  vertical  notch  in  the  edge  of  the  tooth.  A  narrow  furrow  some- 
times passes  upward  from  the  notch  on  both  anterior  and  posterior 
surfaces,  nearly  to  the  gum.  It  is  seen  from  the  above  that  the  ap- 
pearances of  the  permanent  teeth  may  be  an  index  of  the  condition 
of  the  nutrition  of  the  child  in  infancy. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     461 

Teething.  During  the  period  of  infancy  it  is  well  to  remember 
the  influence  of  the  eruption  of  the  teeth  upon  the  general  constitu- 
tion. While  many  prominent  authorities  believe  that  the  eruption 
takes  place  without  the  occurrence  of  general  or  reflex  symptoms, 
equally  careful  observers,  on  the  other  hand,  believe  that  nervous  phe- 
nomena often  attend  the  process.  The  latter  class  of  observers  attrib- 
ute the  feverishness,  insomnia,  restlessness,  loss  of  appetite,  and  gastro- 
intestinal disturbance  to  this  cause.  Convulsions  at  this  period  are 
believed  to  be  due  to  the  pressure  of  the  tooth,  which  cannot  break 
through  the  mucous  membrane,  upon  highly  sensitive  nerves  at  the 
root.  Even  in  later  life  reflex  convulsions  are  held  by  some  to  be  due 
to  teeth. 

Slowness  in  the  development  of  the  teeth  may  be  due  to  rhachitis, 
which  should  be  looked  for.  The  student  should  be  familiar  with  the 
periods  of  development,  the  number  of  teeth  that  appear  at  each 
period,  and  the  date  of  the  eruption. 

Dates  of  Eruption  of  the  Teeth. 
Milk  Teeth. 
2M    1C    41    1C    2M    = 
2M    1C    41    1C    2M 

Eruption  of  central  incisors  about 7th  month.1 

"  lateral  incisors       " 9th  month. 

"  first  molars  " loth  month. 

canines  " 18th  month. 

'•  second  molars       " 24th  month. 

Permanent  Teeth. 
3M    2B    1C    41    1C    2B    3M 
3M    2B    1C    41    1C    2B    3M 

Eruption  of  anterior  molars    about 7th  year. 

"  central  incisors         " 8th  year. 

"  lateral  incisors         " 9th  year. 

anterior  bicuspids    " 10th  year. 

posterior  bicuspids  " 11th  year. 

"  canines  " 11th  year. 

"  second  molars  " 12th  to  14th  year. 

"  third  molars  (wisdom  teeth)  about      .....  18th  to  25th  year. 

Stomatitis. 

This  inflammation  is  not  limited  to  the  mouth  alone,  but  extends  to 
structures  within  the  mouth,  as  the  gums,  and  may  invade  the  tongue. 
The  inflammation  is  recognized  by  the  subjective  and  objective  signs 
common  to  such  inflammations.  There  is  pain,  and  hence  the  child 
(for  it  usually  occurs  in  children)  refuses  to  nurse  or  take  the  bottle, 
or  cries  when  food  is  given.  The  pain  is  accompanied  by  foetor  of  the 
breath.  This  occurs  in  all  forms  of  stomatitis.  Its  origin,  as  well  as 
the  origin  of  the  pain,  is  readily  determined  by  inspection. 

On  inspection  we  note  the  usual  signs  of  inflammation.  They  are 
rarely  general,  being,  as  a  rule,  localized  to  small  areas  which  rapidly 
become  ulcerated.  When  general  the  mucous  membrane  is  red  and 
hot  ;  the  color  extends  to  the  gums,  lips,  and  tongue.     This  is  seen  in 

1  Lower  incisors  first. 


462  SPECIAL  DIAGNOSIS. 

the  catarrhal  form  ;  the  follicles  are  also  enlarged.  The  tongue  be- 
comes red  and  smooth,  or  may  be  covered  with  a  white  coating  through 
which  the  prominent  red  fungiform  papilla?  project.  Accompanying 
the  inflammation  there  is  increased  secretion,  which  dribbles  from  the 
mouth,  or  is  constantly  discharged  by  older  patients.  The  red  hue  of 
the  mucous  membrane  is  attended  by  swelling.  The  heat  of  the  mouth 
is  often  sufficient  to  raise  the  temperature  of  the  exhaled  air  so  that 
the  breath  is  hot. 

A  peculiar  form  of  inflammation  of  the  mouth  is  seen  in  gouty  sub- 
jects. It  occurs  at  intervals.  Pain  is  not  so  marked,  but  the  heat, 
redness,  and  burning  are  a-sociated  with  a  superficial  glossitis  and 
salivation.  The  saliva  is  highly  acid,  and  causes  a  dermatitis  on  the 
chin.  Other  mucous  membranes  are  involved  at  the  same  time,  as 
the  vagina.  An  acid  mucoid  discharge  sets  up  irritation  at  the  vaginal 
outlet  and  causes  much  distress. 

Aphthous  Stomatitis.  Local  areas  of  intense  inflammation  are 
sometimes  followed  by  ulceration.  Thus  in  aphthous  stomatitis  small 
yellowish-white  spots  appear,  at  first  discrete,  but  soon  dotted  over 
the  mucous  membrane  inside  of  the.  cheeks,  in  the  roof  of  the  mouth, 
along  the  sides  of  the  gums  and  on  the  tongue.  They  subsequently 
break  down  into  shallow  ulcers  with  raised  red  margins. 

Aphthous  ulceration  is  seen  in  foot-and-mouth  disease.  The  local 
process  is  characterized  by  greater  swelling  with  softening  and  ulcera- 
tion of  the  soft  parts  than  in  other  stomatitis.  In  foot-and-mouth 
disease  there  is  a  history  of  infection,  profuse  diarrhoea  followed  by 
constipation  and  considerable  physical  depression. 

Ulcerative  Stomatitis.  The  disease  occurs  in  ill-nourished 
subjects,  and  is  often  intercurrent  with  exhaustive  disease,  as  chronic 
diarrhoea.  It  may  be  seen  in  epidemic  forms  in  camps  and  in  penal 
and  other  institutions  on  account  of  unsanitary  conditions.  In  ulcer- 
ative stomatitis  the  inflammation  is  more  pronounced  on  the  gums. 
They  are  swollen,  red,  and  covered  with  ulcers.  The  gums  which  are 
filled  with  teeth  are  affected,  and  the  ulcers  are  usually  at  the  gingival 
border.  The  ulcers  are  covered  with  yellowish  material.  The  flow  of 
saliva  is  much  increased  in  this  affection.  It  is  acid  in  reaction.  The 
submaxillary  glands  are  enlarged.    The  foetor  of  the  breath  is  very  great. 

Thrush  In  parasitic  stomatitis,  or  thrush,  raised  white  patches  are 
seen  looking  like  small  curds  of  milk.  The  patches  vary  in  size,  and 
on  the  tongue  may  cover  an  area  as  large  as  a  three-cent  piece.  The 
\vhite  patches  are  distinguished  from  milk-curds  because  they  cannot 
be  removed  by  the  napkin  or  brush.  It  has  bceen  thought  that  the 
parasite  which  is  the  cause  of  the  inflammation  is  the  o'idium  albicans  ; 
but  Forchcimer  prefers  to  group  it  under  saccharomyces. 

Stomatitis  Materna.  Painful  ulcers  occur  in  the  mucous  mem- 
brane of  the  lips  and  cheeks  in  nursing-women.  They  are  solitary 
and  interfere  with  mastication. 

Gangrenous  Stomatitis.  The  affection  appears  as  a  gangrenous 
inflammation  of  the  gums,  mucous  membrane,  and  deeper  tissues  of 
the  cheek.  At  first  a  small,  dark  red,  hard  spot  is  seen,  which  increases 
in  size,  and  becomes  of  a  purplish  color.     The  cheek  rapidly  becomes 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     463 

swollen,  tense,  and  brawny.  On  the  surface  of  the  more  indurated 
portions  a  bleb  forms  which  soon  breaks  with  rapid  ulceration.  The 
ulcer  is  dark  and  gangrenous  and  soon  perforates  the  cheek.  It  ex- 
tends to  the  jaw  and  is  followed  by  necrosis  of  that  bone.  The  char- 
acteristic odor  of  gangrene  attends  the  process.  While  the  affections 
previously  mentioned  are  generally  dependent  upon  poor  nutrition, 
(/tinr/renous  stomatitis  is  always  secondary  to  depraved,  depressed,  or 
debilitated  states  of  the  system.  Several  cases  may  occur  at  the  same 
time  among  children  living  in  institutions  on  improper  food,  in  which 
the  hygienic  conditions  are-  bad. 

Mercurial  Stomatitis.  Mercurial  stomatitis,  or  ptyalism,  par- 
ticularly affects  the  gums.  It  also  involves  the  salivary  glands.  The 
inflammation  is  caused  by  mercury.  It  may  occur  from  the  medical 
use  of  the  drug,  particularly  in  persons  who  are  unduly  susceptible,  or 
are  not  particular  in  regard  to  mouth-cleansing.  The  inflammation  is 
painful  and  attended  by  profuse  discharge  of  saliva,  hence  the  name, 
salivation.  The  tongue  is  swollen,  marked  on  the  sides  by  the  teeth, 
and  may  be  protruded  with  difficulty  on  account  of  its  size.  It  is 
tender  to  the  touch.  It  is  covered  with  a  heavy,  creamy  coating. 
The  gums  are  swollen,  red,  sore,  and  bleed  on  the  slightest  touch. 
Ulcers  along  the  border  occur,  may  become  extensive,  and  in  some 
instances  extend  to  the  jaw.  The  teeth  become  loosened.  The  fcetor 
of  the  breath  is  heavy,  offensive,  and  of  a  metallic  character.  The 
inflammation  is  usually  preceded  by  a  metallic  taste  in  the  mouth,  and 
the  patient  notices  pain  on  mastication,  which  increases  in  severity  as 
the  inflammation  develops.  In  mild  cases  it  is  limited  to  the  gums, 
in  others  the  tongue  and  salivary  glands  and  the  mucous  membrane  of 
the  mouth  are  affected. 

Leprosy.  This  affection  frequently  invades  the  mouth,  and  particu- 
larly the  nodular  and  ulcerative  lesions  are  seen.  It  is  always  associ- 
ated with  the  characteristic  lesions  of  the  skin.  Scraping  or  sections 
would  show  the  characteristic  micro-organism.  Glanders  may  invade 
the  mouth  from  the  naso-pharyngeal  space.  Carious  teeth  afford 
entrance  for  the  ray-fungus  of  actinomycosis.  Often  there  is  first  dis- 
ease of  the  alveolus,  as  pyorrhoea,  or  a  periosteal  abscess ;  then  the 
jaw  is  involved.      Before  this  a  general  stomatitis  may  be  set  up. 

Ulcers.  In  addition  to  these  forms  of  ulcerative  stomatitis,  soli- 
tary ulcers  are  seen  in  herpes,  secondary  to  gastric  or  uterine  disturb- 
ances, and  the  ulcers  of  syphilis.  The  herpetic  ulcers  are  of  frequent 
occurrence  at  the  menstrual  period  or  during  the  course  of  lactation. 
The  tendency  to  their  formation  is  often  hereditary.  I  have  seen  them 
occur  at  the  menstrual  period  or  in  pregnancy  in  the  women  of  three 
generations.  In  the  secondary  stage  of  syphilis  mucous  patches  arc 
seen  as  bright  red,  symmetrical,  oval  or  crescentic  patches  or  ero- 
sions. They  are  generally  covered  with  a  scanty  grayish-white  secre- 
tion. They  are  not  usually  painful.  They  are  found  on  the  mucous 
membrane,  sometimes  on  the  tongue  and  fauces. 

Sublingual  Ulcer.  This  local  ulcer  is  on  the  frsenum  of  the  tongue. 
It  is  seen  in  whooping-cough,  and  is  due  to  the  rubbing  of  the  tongue 
against  the  teeth  in  the  act  of  couehiuir. 


464  1         SPECIAL  DIAGNOSIS. 

Scleroderma.  This  rare  trophoneurosis  invades  the  mouth.  It  is 
characterized  by  a  submucous  infiltration  of  cartilaginous  hardness, 
the  surface  of  which  is  denuded  of  epithelium  or  covered  with  crusts. 
The  invasion  comes  from  the  nostrils  or  the  naso-pharynx.  Later  the 
infiltration  changes  to  a  yellowish-red  or  a  tendinous-like  scar. 

The  Tongue. 

Examination  of  the  tongue  is  made  for  diagnostic  purposes  with 
a  greater  show  of  wisdom  on  the  part  of  the  examiner,  and  greater 
satisfaction  to  the  patient,  but  with  less  satisfactory  results  from  a 
diagnostic  standpoint,  than  the  examination  of  any  other  portion  of 
the  body.  The  mucous  membrane  of  the  tongue  is  examined  because 
it  is  the  only  mucous  membrane  of  the  body,  except  the  oral  and  faucial, 
which  is  open  to  inspection,  and  is  therefore  supposed  to  enable  us  to 
judge  of  the  effects  of  general  diseases  upon  mucous  membranes.  It 
is  thought  to  be  indicative  of  disorders  of  the  gastro-intestinal  tract 
because  of  its  relations  with  it,  but  recent  studies  by  Hutchinson,  But- 
lin,  and  other  observers  have  resulted  in  the  promulgation  of  differ- 
ent views.  Both  the  above-mentioDed  distinguished  gentlemen  are 
surgeons,  and  look  upon  the  tongue  as  a  local  organ.  Investigating  it 
as  such,  they  concluded  that  the  changes  in  the  coating,  which  had  been 
considered  to  have  so  much  clinical  significance,  depended  largely  upon 
parasitic  invasion,  and  were  not  due  to  changes  in  the  epithelium.  The 
parasitic  invasion,  they  hold,  is  largely  dependent  upon  local  condi- 
tions, which,  it  is  true,  are  on  their  part  dependent  upon  a  state  of  the 
system.  Since  the  writings  of  Hutchinson  and  Butlin,  Dickinson 
returned  to  the  investigation  on  the  lines  laid  down  by  older  teachers, 
and  has,  in  a  measure,  restored  the  tongue  to  its  original  position  as  a 
diagnostic  feature  in  an  estimation  of  the  state  of  the  general  system 
and  in  diseases  of  the  gastro-intestinal  tract. 

We  study  the  tongue  to  ascertain  its  color  ;  the  character  of  erup- 
tions if  they  are  present  ;  the  occurrence  of  indentations,  excoriations, 
furrows,  or  fissures  ;  the  occurrence  of  ulcers  and  of  patches.  Plaques, 
nodes,  and  nodules  are  also  seen  on  the  tongue.  Inflammation  of  the 
tongue  occurs,  and  it  is  the  seat  of  atrophy  and  hypertrophy  and  of 
the  various  tumors  in  the  parasitic  diseases.  The  movements  of  the 
tongue  are  also  observed,  as  an  indication  of  the  power  of  musclea 
which  are  under  centric  influence  closely  related  to  important  centres 
in  the  medulla  oblongata.  Surgical  affections  of  the  tongue  will  not 
be  considered  ;  local  affections  will  only  be  referred  to  in  connection 
with  general  diseases. 

Discolo rations  of  the  Tongue.  Yellowish-white,  oblong  patches, 
soft,  but  slightly  raised,  are  sometimes  seen  along  the  sides  of  the  tongue 
— xanthelasma.  They  are  sharply  defined  and  vary  in  size  from  a 
split  pea  to  a  three-cent  piece.  Xanthelasma  is  also  situated  upon  the 
eyelids  and  upon  the  palms  of  the  hands,  rarely  in  other  portions  of 
the  body.  It  occurs  in  jaundice,  or  in  persons  who  are  said  to  be 
subject  to  bilious  attacks. 

Pigmentations.     Dark  purple,  bluish-black,  or  black  marks  are  seen 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     465 

on  the  tongue  as  well  as  on  the  surface  of  the  lips,  where  they  are  also 
brown.  They  are  sharply  defined,  neither  raised  nor  depressed,  and 
vary  in  size.  Such  pigmented  spots  are  seen  after  glossitis  and  in 
Addison's  disease.  In  the  latter  affection  other  pigmented  areas  are 
found.  Bloodstains  are  observed  in  purpura.  Bright  red  spots 
thdfsize  of  a  split  pea,  or  patches,  or  eechymoses,  are  of  frequent  occur- 
rence. The  color  of  eechymoses  is  not  removed  by  pressure.  Hem- 
orrhagic infarcts  are  sometimes  seen  on  the  tip  of  the  tongue. 

Black  Tongue.  This  rare  condition  is  of  parasitic  origin.  It  has 
recently  been  described  anew  by  Cohen.     It  is  also  known  as  nigrities. 

The  affected  portion  is  of  a  brownish-black  or  black  color,  varying 
in  size  and  usually  situated  in  the  middle  of  the  dorsum  of  the  tongue. 
It  looks  like  an  iron-stain,  and  in  some  instances  the  surface  is  rough- 
ened. The  papillae  are  abnormally  enlarged.  It  usually  begins  as  a 
small  spot,  and  extends  slowly,  so  that  at  the  end  of  a  month  the  dor- 
sum is  covered.  The  centre  is  blacker  than  the  circumference.  After 
the  entire  dorsum  is  covered  the  spot  begins  to  disappear  from  the  cir- 
cumference toward  the  centre,  and  is  followed  by  desquamation  This 
series  of  phenomena  is  repeated  and  the  entire  affection  subsides  slowly. 
Desquamation  may  last  from  a  few  days  to  two  months.  The  papillae 
of  the  affected  surface,  too,  look  like  "  a  field  of  corn  laid  by  the  wind 
and  rain."  The  sensations  of  taste  and  touch  are  not  altered,  but  a 
sensation  of  dryness  is  marked.  It  must  be  remembered  that  a  black 
tongue  is  sometimes  the  result  of  deliberate  deception. 

Inflammation  of  the  Tongue.  Acute  glossitis  is  a  rare  affec- 
tion, more  common  in  adults  than  in  children,  and  more  frequent  in 
men  than  in  women.  It  occurs  more  frequently  in  the  summer.  The 
onset  is  rapid.  After  a  short  period  of  tenderness  on  mastication  the 
movements  of  the  tongue  are  stiff  and  painful,  or  there  are  pains  in 
the  muscles  of  the  neck  and  submaxillary  region.  In  a  few  hours 
the  tongue  swells.  It  rapidly  increases,  and  at  the  end  of  fifteen  to 
twenty  hours  is  three  times  its  natural  size,  protrudes  from  the  mouth, 
is  indented  by  the  teeth,  and  is  almost  immovable,  feeling  heavy,  pain- 
ful, and  tender.  It  is  coated  with  a  thick  fur  on  the  dorsum.  Sali- 
vation accompanies  these  symptoms,  speech  is  impossible,  dysphagia 
extreme,  and  dyspnoea  not  unusual-.  The  glands  underneath  the  jaw 
are  swollen.  The  temperature  rises  to  101°,  rarely  above  it,  even  if 
the  case  is  severe.  Death  may  occur  in  a  few  hours  from  suffocation, 
or  after  a  longer  interval  from  diffuse  suppuration,  gangrene,  exhaust- 
ing septic  fever,  or  pneumonia.  Gangrene  is  more  frequent  than  spon- 
taneous resolution.  If  resolution  is  to  be  established,  the  swelling 
begins  to  subside  in  three  or  four  days.  Small  ulcers  form  on  the 
surface  of  the  tongue,  and  by  the  end  of  a  week  its  normal  appearance 
is  regained.  The  fever  and  distressing  symptoms  subside  with  the 
local  swelling.  It  is  said  to  be  due  to  colds,  to  bites  and  stings  of 
animals,  to  mercury,  and  to  corrosive  and  acrid  substances.  It  may 
occur  in  fevers.  The  diagnosis  is  easy.  It  must  be  distinguished  from 
acute  (Edematous  swelling  due  to  salivary  calculus  or  affections  of  the 
floor  of  the  mouth.  Acute  ranula  sometimes  causes  considerable  swell- 
ing of  the  tongue,  simulating  acute  glossitis.     ITemiglossitis  sometimes 

30 


466  SPECIAL  DIAGNOSIS. 

occurs.  The  local  symptoms  are  not  so  great,  because  only  half  of 
the  mouth  is  occluded.  I  saw  a  case  in  which  the  inflammation  was 
limited  to  half  the  side  of  the  tongue  on  the  posterior  surface.  It 
went  on  to  suppuration,  but  was  not  attended  by  serious  symptoms, 
except  discomfort  in  eating.  It  was  preceded  by  a  definite  nodule  in 
the  substance  of  the  inflamed  part.  Glossitis  from  mercurial  poison- 
ing has  been  described  in  connection  with  stomatitis. 

Chronic,  Superficial  Inflammation  of  the  tongue  may  also  occur. 
The  surface  is  smooth  and  deprived  of  papilla?  over  the  affected  area, 
which  is  redder  than  natural.  The  margin  of  the  raw  patch  is  sharply 
defined,  but  the  area  has  no  depth.  The  epidermis  alone  is  removed. 
When  associated  with  dyspepsia  it  covers  a  considerable  area  of  the 
surface  of  the  tongue.  The  tongue  may  be  deprived  of  papillae  on  the 
front  part  of  the  dorsum  while  the  fungiform  papillae  remain.  One 
observer,  Hack,  has  described  these  ulcers  as  peculiar  to  women  and 
hereditary.  He  observed  a  row  of  long,  oval  areas.  They  commenced 
in  early  childhood.  The  tongue  was  strikingly  smooth  over  remaining 
large  areas,  with  red  excoriations  here  and  there.  There  was  no  syph- 
ilis. In  chronic  superficial  glossitis,  we  find  excoriations  due  to  slight 
traumatism  or  to  dyspepsia. 

Eruptions.  Eruptions  of  variola,  measles,  and  erysipelas  are  seen 
on  the  tongue.  Herpes  and  aphthous  ulcers,  preceded  by  vesicles,  are 
met  with  on  the  surface  of  the  tongue. 

Indentations  occur  when  the  tongue  is  swollen,  as  in  mercurial 
and  other  forms  of  glossitis.  The  borders  of  the  tongue  are  indented 
by  the  pressure  of  the  teeth.  In  states  of  debility  a  flabby  tongue 
with  indented  borders  is  often  seen.  Sometimes  the  swelling  is  so 
great  that  the  pressure  of  the  teeth  causes  ulceration. 

Excoriations  on  the  surface  of  the  tongue,  or  rawness,  arise  from 
injury,  and  may  also  be  seen  in  dyspepsia. 

Furrows,  or  Grooves  and  Wrinkles,  are  seen  on  the  dorsal 
aspect  of  the  tongue.  They  are  not  necessarily  tokens  of  disease  ;  in 
many  persons  they  are  of  constant  occurrence.  Furrows  vary  from  a 
few  lines  to  an  inch  or  more  in  length.  In  many  this  is  most  striking 
in  the  middle  line  of  the  tongue.  The  median  furrow  is  liable  to 
become  ulcerated  on  slight  provocation.  The  edges  of  the  fissures  are 
smooth  and  without  papilla?  or  fur.  Other  furrows  are  directed  longi- 
tudinally and  vary  in  depth.  They  may  be  curved  and  forked.  They 
are  more  frequent  in  older  persons,  especially  if  the  tongue  is  too  large 
to  lie  within  the  circle  of  the  teeth.  They  are  an  evidence  of  past 
inflammation,  or  rarely  of  hypertrophy.  They  resemble  i-he  median 
furrows  as  regards  smoothness  and  absence  of  fur.  Inflammatory 
furrows  occur  in  chronic  superficial  inflammation,  but  more  commonly 
after  chronic  inflammation  which  ha*s  left  the  tongue  enlarged.  The 
furrows  are  sometimes  so  abundant  that  the  surface  of  the  tongue  looks 
like  the  eyelid.  The  raised  areas  become  sore,  due  to  irritation  of  a 
foreign  body  (food)  or  a  tooth.  They  are  an  indirect  result  of  inflam- 
mation. True  inflammatory  furrows,  described  as  dissecting  glossitis 
by  Wunderlich,  occur.  Dissecting  glossitis  is  only  a  more  aggravated 
form  of  superficial  glossitis.     Furrows  of  this  character  may  be  due  to 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     467 

syphilis,  and  dissecting  glossitis  sometimes  has  a  syphilitic  origin. 
Fissures  and  clefts  are  frequently  caused  by  the  rubbing  and  deep 
indentation  of  a  rough  and  jagged  tooth.  The  area  around  the  fissure 
is  inflamed  and  its  base  indurated.  The  sides  and  bottom  are  ulcerated. 
It  is  recognized  by  its  relation  with  the  offending  tooth.  It  may  be 
mistaken  for  syphilis,  another  common  cause  of  fissures. 

Syphilitic  Lesions.  It  must  be  remembered  that  the  tongue  is 
always  predisposed  to  inflame  and  ulcerate  in  syphilis.  In  secondary 
syphilis  fissures  are  always  found  on  the  borders  of  the  tongue  ;  they 
are  almost  certain  to  occur  if  the  teeth  irritate  the  border.  They  may 
be  due  to  the  ulceration  of  a  mucous  tubercle  which  is  developed  upon 
the  border  of  the  tongue.  The  ulcer  is  stellate,  and  gradually  deepens 
until  it  becomes  a  foul  fissure.  Two  processes  cause  the  ulceration — 
the  specific  infection  and  the  irritation  of  the  teeth.  Syphilitic  ulcers 
are  not  very  angry,  as  are  non-syphilitic  sores  and  fissures  which  may 
occur  in  persons  in  poor  health.  They  may  be  sensitive,  however,  on 
account  of  the  involvement  of  the  tongue.  The  absence  of  active 
inflammation,  the  large  number  of  the  sores  and  fissures,  and  the  asso- 
ciation with  other  lesions  of  the  disease  upon  the  tongue,  cheeks,  and 
lips  point  to  their  syphilitic  origin.  Tertiary  syphilitic  ulcers  are  more 
pronounced  and  deeper  than  other  forms.  They  may  be  as  long  as 
two  or  three  inches  ;  they  are  sinuous  and  branched.  Gummata  may 
occur  on  the  tongue  at  the  same  time  The  gummata  may  be  circum- 
scribed or  linear,  and  may  degenerate  and  ulcerate.  Sclerosis  of  the 
tongue,  as  described  by  Fournier,  follows  the  healing  of  these  ulcers. 
It  is  curious  to  note  that  the  lymphatic  glands  are  seldom  enlarged  in 
association  with  syphilitic  fissures.  The  fissures  must  be  distinguished 
from  carcinoma  and  tuberculosis.  In  carcinoma  there  is  a  distinct 
tumor,  which  may  become  fissured.  Tuberculous  ulceration  is  a  sign 
of  the  presence  of  tubercle  in  other  organs.  The  tuberculous  fissures 
are  small,  at  first  single  ;  tubercle,  however,  rarely  begins  as  a  fissure, 
but  as  tuberculous  ulcers  on  the  tip  or  borders  of  the  tongue.  They 
are  stellate  or  irregularly  branched.  They  are  shallow  at  first,  and 
deepen  later,  but  do  not  widen  in  a  corresponding  manner.  The 
lymphatic  glands  are  always  involved  (see  Tuberculous  Ulcer). 

Ulcers  of  the  Tongue.  They  may  be  simple,  aphthous,  or 
traumatic.  Simple  ulcers  follow  long-standing  superficial  glossitis. 
They  form  in  the  centre  of  the  tongue,  or  of  the  diseased  inflamma- 
tory area.  They  are  due  to  sloughing,  or  simple  melting  away  of 
epithelium.  The  ulcer  is  smooth,  red,  glazed  on  the  surface.  The 
edges  are  callous  and  inactive,  the  shape  is  irregular.  It  is  sensitive, 
and  may  be  painful.  The  signs  of  chronic  glossitis  continue  with  it. 
Dyspeptic  or  catarrhal  ulcers  occur  on  the  tip,  or  on  the  dorsum  near 
the  tip.  The  dorsum  of  the  tongue,  from  the  tip  backward,  is  very 
red,  and  filiform  papillae  are  absent.  The  ulcers  are  small  and  super- 
ficial without  definite  shape  or  character,  except  that  they  arc  red  and 
irritable  Dyspeptic  ulcers  may  occur  from  the  breaking  down  of 
vesicles  on  the  tongue.  They  are  small,  circular,  well-defined  ulcers, 
with  sharp-cut  edges,  in  size  from  a  pin's  head  to  a  split  pea,  and  are 
the  source  of  considerable  pain  and  much  annoyance.    They  are  recur- 


468  SPECIAL  DIAGNOSIS. 

rent.  Salivation  may  attend  them.  Aphthous  ulcers  are  seen  in  chil- 
dren and  adults,  and  are  attended  with  the  same  symptoms  as  aphthous 
ulcers  of  the  mouth,  with  slight  fever.  Foetor  is  characteristic.  Trau- 
matic ulcers  from  sharp  teeth  may  persist  a  long  time  if  the  general 
health  is  bad.  When  active  they  may  be  mistaken  for  syphilitic  sores, 
and  when  indolent  for  syphilitic,  tuberculous,  or  cancerous  ulcers.  The 
rapidity  of  formation,  the  location  opposite  a  rough  tooth,  and  the 
absence  of  other  signs  of  syphilis  point  to  the  true  nature  of  the  ulcer. 
Chancre  can  be  excluded  by  the  greater  hardness  and  circumscription 
of  the  lesion,  its  seat  near  the  tip,  and  its  association  with  enlargement 
of  the  lymphatic  glands.  The  latter  is  not  present  in  traumatic  ulcer, 
unless  it  is  acute  and  aDgry.  Traumatic  ulcer  is  distinguished  from 
tuberculous  ulcers  by  the  absence  of  signs  of  tubercle  in  other  organs 
and  by  the  result  of  an  examination  of  the  scrapings  of  the  ulcer  ; 
from  cancer  by  the  age.     In  cancer  all  the  glands  become  affected  later. 

Tuberculous  Ulcer.  The  tuberculous  ulcer  presents  an  uneven, 
pale,  flabby  surface,  covered  with  a  yellowish-gray  viscid  or  coagulated 
mucus.  The  edges  are  sometimes  sharp-cut,  sometimes  bevelled,  sel- 
dom elevated.  They  are  not  usually  very  red.  There  is  but  little 
surrounding  inflammation,  and  the  adjacent  portions  of  the  tongue  are 
but  slightly  swollen.  The  borders  of  the  ulcer  may  be  sinuous,  and 
the  shape  oval  or  ovoid,  or  elongated.  In  the  neighborhood  of  an 
ulcer  a  number  of  tiny  yellowish  gray  points  may  be  observed.  The 
ulcer  is  painful,  and  attended  by  salivation.  I  saw  in  the  Philadelphia 
Hospital  a  case  of  tuberculous  ulcer  of  the  tongue,  in  a  young  man 
twenty  five  years  of  age,  with  pulmonary  and  intestinal  tuberculosis. 
The  dorsum  of  the  tongue  was  covered  with  a  dozen  ulcers  with 
sharp-cut '  edges  and  pale,  flabby  granulations,  without  induration  or 
inflammation  around  them.  They  were  yellowish-gray,  and  tubercle 
bacilli  were  found  in  the  scrapings.  Tubercle  ulcer  must  always  be 
carefully  distinguished  from  syphilitic  and  cancerous  ulceration.  The 
associate  symptoms  are  often  most  reliable.  Ulcers  due  to  lupus  are 
also  seen  upon  the  tongue. 

Patches  and  Plaques.  Space  forbids  further  consideration  than 
the  naming  of  the  plaques  which  are  seen  on  the  tongue.  First,  there 
is  the  smoker's  patch  on  the  middle  of  the  dorsum  about  the  point 
where  the  tobacco-pipe  rests,  or  where  the  stream  of  smoke  from  the 
pipe  or  segar  strikes  the  tongue.  This  is  a  slightly  raised  area  of  oval 
shape.  It  is  not  ulcerated,  but  is  smooth  and  red,  or  livid.  Some- 
times it  is  bluish-white  or  pearly  in  appearance.  The  smoothness  is 
characteristic.  White  and  bluish-white  patches  or  plaques  are  seen 
in  leucoma,  leucoplakia,  ichthyosis,  keratosis,  and  are  also  known  as 
opaline  plaques.  The  smoker's  patch  belongs  to  the  same  class,  and 
is  probably  an  early  stage  of  these  affections.  It  is  a  whiteness,  or  white 
opacity  of  the  surface  of  the  tongue,  usually  on  the  dorsum.  It  is 
almost  always  the  result  of  the  direct  action  of  irritants.  These  patches 
are  unknown  under  twenty  years  of  age,  do  not  commence  after  sixty, 
and  very  rarely  attack  women.  They  are  not  attended  by  subjective 
symptoms  usually.  There  may  be  a  sensation  of  induration  and  dry- 
ness.    The  course  is  always  chronic. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     469 

Chronic  Superficial  Glossitis.  The  whole  dorsal  aspect  of  the 
tongue  is  smoother  than  natural,  the  mucous  membrane  is  redder  than 
the  normal,  the  surface  uneven.  The  papillae  have  disappeared.  Ex- 
coriations and  superficial  ulcers  usually  accompany  the  inflammation. 
The  tongue  is  enlarged  and  its  borders  marked  by  the  teeth.  The 
surface  looks  glossy.  The  tongue  feels  stiff  and  uncomfortable. 
Movement  is  irksome,  irritating  foods  are  painful.  Spirits  and  tobacco 
cause  distress.  Indiscretions  in  diet  quickly  produce  fresh  inflamma- 
tions. 

Wandering  Rash.  Ringworm  or  circular  exfoliations  occur  most 
frequently  in  children.  One  or  more  patches  on  the  surface  of  the 
dorsum  of  the  tongue  are  observed,  smooth  and  red,  but  not  depressed 
or  elevated.  The  filiform  papilla?  have  been  shed.  The  patch  spreads 
and  becomes  a  ring,  circular  or  oval.  The  border  is  faintly  or  decid- 
edly yellow,  and  usually  slightly  raised  and  sharply  defined.  The 
circles  may  widen  and  contract  from  time  to  time.  No  subjective  symp- 
toms are  noted  except  itching  in  a  few  cases.  The  cause  is  not  known. 
The  diagnosis  is  easy.     It  may  continue  for  months  or  years. 

Mucous  Patches  are  multiple  lesions  of  syphilis  in  the  mucous 
membrane.  They  have  been  referred  to  in  the  section  on  Diseases  of 
the  Mouth. 

Nodes  or  nodules  in  the  tongue  are  always  tuberculous  or  syphilitic. 

Atrophy  of  the  tongue  is  very  unusual  ;  hemiatrophy  may  occur 
as  the  effect  of  central  or  peripheral  causes,  as  softening,  hemorrhage, 
or  tumors  of  the  region  of  the  hypoglossal  nucleus.  Other  centres 
near  the  nucleus  are  affected,  hence  other  forms  of  paralysis  are  seen, 
due  to  the  lesions  of  the  medulla.  These  are  seen  in  progressive  mus- 
cular atrophy  and  bulbar  paralysis,  and  in  cases  of  hemiplegia.  It 
is  not  difficult  to  recognize  it  on  inspection.  The  functions  of  the 
tongue  are  not  affected. 

Hypertrophy  of  the  tongue,  or  macroglossia,  is  generally  congen- 
ital, but  may  occur  late  in  life.  The  tongue  enlarges,  and  is  accom- 
panied by  pressure  symptoms,  due  to  such  enlargement.  Hypertrophy 
of  the  tongue  is  sometimes  seen  in  idiots  and  cretins.  The  hypertrophy 
is  more  frequently  the  result  of  lymphatic  obstruction,  on  account  of 
which  there  is  lymph-stasis  The  diagnosis  is  easy.  Inflammatory 
hypertrophy  occurs  in  stomatitis,  and  syphilitic  hypertrophy  occurs 
with  gummata. 

Cysts.  Various  cysts  occur  in  the  tongue.  Mucous  cysts  and  blood- 
cysts  are  the  most  common.  The  cysticercus  cellulosse,  and  the  echin- 
ococcus  occur  rarely.  Ranula  is  a  cyst  underneath  the  tongue  that 
causes  mechanical  suffering.     It  is  easy  of  recognition. 

Parasitic  Disease  of  the  Tongue.  Thrush  is  the  most 
common. 

The  Effects  of  Gexeral  or  Remote  Disease  on  the  Tongue. 
The  Coating.  With  a  view  to  estimating  the  condition  of  the  system 
in  general  from  the  appearances  of  the  tongue,  excluding  all  local 
conditions,  the  following  characteristics  are  observed  :  first,  the  color; 
second,  the  fur;  third,  the  degree  of  moisture;  and,  fourth,  the  move- 
ments.    The  student  should  bear  in  mind  that  changes  in  the  condition 


470  SPECIAL  DIAGNOSIS. 

of  the  tongue  are  frequently  of  local  origin;  that  dryness,  for  instance, 
may  be  due  to  the  open  mouth,  or  that  a  coating  may  be  unusually 
marked  because  the  tongue  had  not  been  used  in  mastication.  Often 
coating  is  seen  on  one  side  of  the  tongue.  This  has  been  referred  to 
as  due  to  disease  of  the  nerves  of  one  side.  It  is  just  as  likely  to  be 
due  to  an  absence  of  mastication  on  that  side  of  the  mouth,  the  bolus 
of  food  being  kept  on  the  other  side  because  of  pain,  diseased  teeth, 
or  other  local  cause. 

Clinical  experience  has  shown  that  certain  conditions  in  the  tongue 
are  associated  with  certain  general  conditions  which  render  the  appear- 
ance somewhat  diagnostic.  The  term  diagnostic  must  be  qualified 
because  the  changes  are  so  often  local,  or  are  modified  by  conditions 
independent  of  the  general  system.  For  convenience,  the  classification 
of  Dickinson  as  to  the  appearance  of  the  tongue  in  disease  may  be 
utilized.  In  the  Lumleian  lectures  this  eminent  authority  described 
the  average  healthy  tongue  based  on  extensive  observations.  Depart- 
ures from  the  normal  were  arranged  and  afterward  classified.  It 
resulted  in  the  formation  of  eleven  classes: 

1.  The  Stippled  or  Doited  Tongue..  The  tongue  is  moist  and  dotted 
with  little  white  points,  due  to  an  excess  of  white  epithelium  on  the 
papilla?.  It  is  usually  seen  in  persons  in  poor  health  without  fever. 
It  is  not,  therefore,  a  febrile  tongue,  nor  one  indicative  of  grave  con- 
stitutional disease.  It  is  seen  in  cases  of  chronic  disease,  usually  one 
in  which  there  are  no  grave  symptoms 

2.  The  Dry  Stippled  Tongue  is  found  in  mildly  acute  diseases,  or  in 
cases  in  which  the  constitutional  disturbance  is  more  marked. 

3.  The  Stippled  and  Coated  Tongue.  The  patients  in  whom  this  is 
found  are  very  frequently  the  subjects  of  acute  and  constitutional 
affections.     Fever  is  more  frequently  present  with  this  variety  of  fur. 

4.  The  Coated  Tongue.  There  is  excess  of  white  epithelium  on 
the  papilla?,  and  the  coat  is  continuous.  The  intervals  between  the 
papilla?  are  more  commonly  filled  up  with  epithelium  and  accidental 
matters  than  in  the  preceding  types.  It  is  seen  in  acute  and  febrile 
diseases,  and  whether  moist  or  dry,  in  pneumonia,  pleurisy,  and  typhoid 
fever.  It  is  associated  with  a  far  greater  degree  of  prostration  and 
pyrexia,  while  the  saliva  is  absent  in  a  larger  proportion  of  the  cases. 

5.  The  Strawberry-tongue.  The  tongue  is  coated  and  injected;  the 
fungiform  papilla?  shine  through  the  coat,  particularly  at  the  tip  and 
edges.  It  is  the  tongue  of  scarlet  fever,  but  may  often  be  seen  in  any 
acute  febrile  disorder.  In  scarlet  fever,  however,  it  appears  by  the 
second  or  third  day — most  marked  after  the  second.  Pyrexia  is  more 
common  in  this  class  than  in  the  preceding. 

6.  Ihe  Plaster-tongue.  A  thick,  uniform  coat,  edges  abrupt  and 
striking,  covers  the  tongue.  The  papillae  are  elongated  and  the  inter- 
vals crowded  with  accumulations,  among  which  are  bacteria  ;  it  is 
the  tongue  of  acute  ferbile  disease.  Fever  was  marked  in  a  number 
of  cases  Dickinson  studied,  and  prostration  was  a  common  attendant. 
Saliva  was  deficient  It  is  thus  seen  that,  beginning  with  the  healthy 
tongue,  Dickinson  described  a  series  of  groups,  in  each  succeeding  one 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  CESOPHAGUS.     471 

the  coating  becoming  more  marked,  with  or  without  moisture.  The 
clinical  association  that  he  found  is  a  common  experience.  Each  suc- 
cessive group  was  attended  by  more  fever  and  greater  exhaustion  and 
less  saliva  than  the  preceding  group,  and  in  each  the  tongue  became 
more  and  more  furred. 

7.  The  Furred  or  Shaggy  Tongue.  When  moist  the  papillae  are 
greatly  elongated,  composed  mostly  of  horny  epithelium.  It  has 
the  same  appearance  as  if  the  tongue  were  dry.  The  moist,  furred 
tongue  is  not  so  common  as  the  other.  It  is  most  commonly  seen  in 
old  age  and  in  constipation.  The  dry,  furred,  or  shaggy  tongue  may 
succeed  the  dotted  tongue  or  the  coated  tongue  in  the  course  of  advanc- 
ing disease.  It  is  the  result  of  disease  and  want  of  moisture.  The 
saliva  is  deficient  ;  it  indicates  that  there  has  been  fever,  and  that 
possibly  but  little  food  was  taken. 

8.  The  Inerusted,  Dry  Brown  Tongue.  Over  the  surface  of  the 
tongue  there  is  a  dry,  thick,  felted  coat,  which  is  continuous  and  dips 
down  between  the  papillae.  The  coat  is  largely  made  up  of  parasitic 
material.  In  the  course  of  fevers  it  is  the  outcome  of  a  preceding 
condition,  the  coated  tongue,  and  is  indicative  of  the  typhoid  state. 
It  occurs  in  the  fevers  with  high  temperature,  but  may  be  seen  in 
conditions  of  low  temperature,  as  from  cancer,  phthisis,  albuminuria, 
chronic  nervous  diseases.  There  is  much  depression  or  prostration 
associated  with  it,  and  there  is  absence  of  saliva.  If  the  patients  with 
a  dry  brown  tongue  recover,  it  retrogresses  to  the  furred  or  inerusted 
tongue,  which  in  turn  becomes  bare  gradually,  at  first  in  small  layers; 
it  is  thin,  usually  dry,  but  is  more  moist  than  the  dry  brown  tongue. 
As  the  incrustation  disappears  it  may  become  bare,  red,  and  dry. 

9.  The  Red  Dry  Tongue  indicates  a  more  serious  condition  usu- 
ally than  the  dry  and  brown.  It  is  the  tongue  of  chronic  wasting  dis- 
eases. It  occurs  in  phthisis  in  the  later  stages,  and,  as  the  raw-beef 
tongue,  is  associated  with  dysentery,  and  also  with  liver  abscess. 
There  may  be  fever  associated  with  the  cases.  It  is  in  a  measure  the 
tongue  of  chronic  diarrhoea.  The  tongue  is  shrunken,  red,  polished, 
and  smooth.  The  papillae  have  disappeared  and  the  epithelium  is 
stripped  off  in  patches.  It  may  be  associated  with  aphthae.  If  the 
patient  is  to  improve,  the  redness  fades,  the  papillae  become  softer, 
and  the  moisture  returns. 

10.  Red  and  Membranous  ;  otherwise  as  (9)  the  red  denuded  tongue. 

11.  Cyanosis,  or  Venous  Congestion  of  the  Tongue.  The  tongue 
is  of  a  bluish  or  purplish  color,  the  surface  is  smooth  and  wet, 
and  the  papillae  are  almost  indistinguishable.  It  is  not  confined  to 
organic  heart  disease  or  cyanosis.  It  is  of  quite  frequent  occurrence  in 
albuminuria.  With  the  venous  congestion  in  the  albuminuric  cases 
there  is  always  a  superabundance  of  deep  epithelium.  When  the  sur- 
face is  examined  it  looks  as  if  the  papillae  were  fused  together,  and 
overlaid  bv  a  moderate  coat. 


472 


SPECIAL  DIAGNOSIS. 


Classification  of  Tongues. 


To  the  naked  eye. 
1.  Healthy,  moist. 

Microscopically. 
White  epithelium  in  small  amount  on  papillae,  not  con- 
tinuous or  superabundant. 

2.  Stippled,  moist,  dotted  with  white. 
2  (D)i.  Stippled,  dry. 

Excess  of  white  epithelium  on  papillae,  not  extending 
between  them. 

Ditto. 

3.  Stippled+coated  ;  moist.  Coat  con- 
tinuous in  parts. 

White  epithelium  on  papillae  in  excess,  with  partial  filling 
of  intervals. 

4.  Coated  white ;    moist.     Coat  con- 
tinuous. 

4  (D).  Coated  white,  dry.     Coat  con- 
tinuous. 

Excess  of  white  epitbelium  in  papillae.   Intervals  more  or 
less  filled  up  with  epithelium  and  accidental  matters. 

Ditto. 

5.  Strawberry,  coated +injected,  espe- 
cially showing  in  fungiform  papillae 

Like  the  coated  or  plastered,  but  with  more  injection. 

6.  White,   plastered,   thick,    uniform 
coat ;  edges  abrupt  and  striking. 

More  elongation  of  papillae  than  with  coated  tongue,  more 
filling  of  intervals  with  superficial  accumulation 

7.  Furred  or  shaggy,  moist.    Greatly 
elongated  papillae. 

7  (D).  Furred  or  shaggy,  dry. 

Extravagantly  long  papillae,  mostly  of  horny  epithelium. 
Ditto. 

8   Incrusted ,  dry,  brown ;  thick,  felted 
dry  coat  over  papillae. 

Continuous  crust   on   and  between  papillae,  largely  of 
parasitic  matters. 

9.  Furred  orincrusted, becoming  bare. 
Generally  dry. 

Crust  breaking  away,  together  with  more  or  less  of  normal 
surface. 

10.  Red,  denuded.    Absence  of  normal 
covering. 

General  absence  of  all  epithelium  excepting  the  Mal- 
pighian  layer ;  sometimes  of  that  also. 

11.  Red,    smooth,    dry,    membranous 
covering. 

Level  membrane  replacing  epithelial  processes. 

12.  Cyanosed. 

Injected  ;  hypernucleated  ;  excess  of  deep  epithelium. 

Moisture  of  the  Tongue.  The  moisture  is  due  to  the  saliva, 
any  deficiency  of  which  causes  dryness  of  the  tongue.  It  is  natural, 
therefore,  to  conclude  that  any  changes  in  the  moisture  of  the  tongue 
are  due  to  the  secretion  of  the  salivary  glands.  Fever  is  almost  always 
present  when  this  is  deficient,  and  hence  the  tongue  is  dry.  At  the 
same  time  this  failure  of  secretion  of  the  salivary  glands  does  not 
attend  the  gastro-iutestinal  tract, 

Dryness  of  the  tongue,  it  must  not  be  forgotten,  may  be  due  to 
increase  of  evaporation  due  to  exposure  of  the  mouth  by  persistently 
keeping  it  open,  besides  diminution  of  the  salivary  secretion.     All 

1  The  letter  D  is  used  to  imply  dryness.    Thus,  to  Class  2  a  certain  description  is  attached.    Class 
2  D  presents  the  same  characteristics  with  the  addition  of  dryness. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  CESOPHAGUS.     473 

states,  therefore,  in  which  the  mouth  is  open  will  lead  to  dryness  of  the 
tongue.  Again,  in  chronic  fever,  dryness  of  the  tongue  is  a  constant 
characteristic.  Dryness  is  due  to  the  effects  of  the  temperature  upon 
the  secretions  in  general,  but  it  is  not  the  effect  of  high  temperature, 
curiously,  but  rather  a  temperature  which  has  persisted  for  a  consider- 
able length  of  time.  Thus,  in  pneumonia,  with  a  temperature  of 
105°,  the  tongue  may  be  moist;  whereas,  in  typhoid  fever,  with  a  tem- 
perature of  103°,  the  tongue  is  dry.  General  dehydration  of  the  body 
causes  dryness  of  the  tongue,  even  without  local  diminution  of  secre- 
tion. This  dehydration  is  seen  in  diarrhoea,  in  which  diseace  simple 
or  uncomplicated  dryness  of  the  tongue  is  the  common  symptom.  It 
is  curious  to  observe  that  in  cholera  the  tongue  remains  moist  even 
until  death  ;  whereas,  if  the  patient  is  about  to  improve  and  the  dis- 
charges cease,  reaction  and  fever  setting  in,  the  tongue  begins  to  dry 
and  becomes  quite  brown.  Local  causes  may  explain  this.  The 
watery  vomit  may  keep  the  tongue  moist,  and  the  temperature  of  the 
body  may  contribute  to  the  change.  Next  after  diarrhoea  we  have 
excessive  discharge  of  urine  as  a  frequent  cause  of  dryness.  Hence, 
in  diabetes  in  all  forms  extreme  dryness  of  the  tongue  is  seen.  The 
osmotic  action  of  the  sugar  in  the  blood  is  the  cause  of  a  reaction  in 
diabetes  mellitus,  just  as  it  is  in  cases  of  dehydration  of  the  lens  in 
cataract.  The  final  cause  of  dryness  of  the  tongue  is  prostration. 
Asthenia  in  all  forms  continuing  over  a  moderate  period  of  time,  as  a 
week  or  ten  days,  causes  lingual  dryness. 

The  Effecls  of  Food.  These  must  be  studied  before  deciding  upon 
the  clinical  significance  of  changes  in  the  tongue.  The  immediate 
results  of  taking  of  food  influence  the  coating  and  the  degree  of  mois- 
ture. The  act  of  eating  cleanses  the  tongue.  In  disease,  therefore,  in 
which  this  act  is  not  performed,  it  is  natural  that  we  observe  more 
fur  on  the  surface,  and  in  conditions  in  which  diet  is  limited  to  fluids 
the  effect  is  marked.  In  cases  of  liquid  diet  the  tongue  is  likely  to 
remain  furred.  It  is  particularly  seen  in  patients  who  are  kept  upon 
a  milk-diet  exclusively. 

The  Tongue  lv  B  elation  to  Diseases  op  the  Alimentary 
Canal.  So  much  has  been  written  on  this  subject  that  it  is  well  to 
give  the  experience  of  Dickinson  briefly.  He  declares  that  he  has 
not  been  able  to  discern  any  relationship  between  any  state  of  the 
tongue  and  dyspepsia,  or  ulcer  of  the  stomach,  apart  from  that  which 
might  occur  from  loss  of  appetite  or  limitation  of  the  food.  With 
regard  to  the  bowels,  some  forms  of  coustipation  are  often  connected 
with  changes  in  the  tongue,  but  such  connection  is  not  constant.  The 
author  rather  thinks  it  to  have  been  a  coincidence,  and  cannot  even 
point  to  the  diagnostic  significance  of  the  tongue  in  obstruction.  The 
state  of  the  tongue  in  the  latter  condition  is  dependent,  not  upon  the 
intestinal  lesion,  but  upon  the  constitutional  disturbance.  A  dry  tongue 
is  well  known  to  occur  in  acute  obstruction.  He  thinks  that  this  is 
due  to  deficiency  of  salivary  secretion;  uuless,  however,  there  is  con- 
stitutional disturbance,  he  does  not  think  that  in  chronic  obstruction 
the  tongue  will  change.  In  diarrhoea  all  conditions  of  dryness,  furring, 
and  incrustation  are  observed.     The  absence  of  saliva,  dehydration, 


474  SPECIAL  DIAGNOSIS. 

and  pyrexia  help  the  desiccation.  In  diarrhoea  and  dysentery,  there- 
fore, the  change  in  the  appearance  of  the  tongue  is  more  marked  than 
in  any  other  disease. 

Other  Diseases.  As  regards  the  relation  of  the  tongue  to  other 
individual  diseases  but  little  can  be  said.  Of  more  direct  association, 
we  have  the  cyanotic  tongue  in  heart  disease;  the  dry  tongue  in  chronic 
albuminuria  and  diabetes  mellitus  ;  the  strawberry-tongue  of  scarlet 
fever;  and  the  dry  brown  tongue  of  typhoid  fever.  Of  course,  the 
so-called  typhoid  tongue  represents  but  one  stage  of  typhoid  fever. 
Throughout  the  disease  it  mav  present  all  varieties  iu  direct  succes- 
sion, from  the  stippled,  the  coated,  the  plastered,  the  furred,  to  the 
incrusted.  In  lobar  pneumonia  the  same  changes  occur  as  the  disease 
advances.  In  bronchitis  the  lower  degrees  of  coating  are  presented, 
while  in  rheumatism  the  variety  is  considerable.  In  conclusion,  it 
may  be  stated  that  the  tongue  seldom  points  to  solitary  organs  or 
isolated  disorders,  but  is  a  gauge  of  the  effects  of  disease  upon  the 
system. 

The  Tongue  in  Prognosis  and  Treatment.  Clinical  observers 
agree  with  Dickinson  that  the  condition  of  the  tongue  is  due  very 
largely  to  the  four  states  with  which  he  has  associated  it — dehydration, 
exhaustion,  pyrexia,  and  local  conditions  about  the  mouth.  As  these 
conditions  modify  the  state  of  the  tongue,  it  is  evident  that  the  first 
sign  of  improvement,  as  return  of  moisture,  denotes  a  diminution  in 
temperature.  Its  appearance  is,  therefore,  of  good  prognostic  omen. 
The  degree  of  fever,  the  state  of  the  nervous  system,  the  mainte- 
nance or  abeyance  of  secretions,  and  the  failure  of  vitality,  are  indi- 
cated by  the  condition  of  the  tongue.  The  return  of  moisture,  the 
removal  of.  fur,  the  subsidence  of  tremor,  at  once  indicate  that  the 
patient  is  getting  better.  The  persistence  and  increase  of  these  signs 
show  that  the  disease  is  getting  the  better  of  the  patient.  As  to  indi- 
cations for  treatment,  the  dryness,  furring,  and  incrustation  are  con- 
nected with  the  want  of  saliva.  The  processes  by  which  this  want  is 
brought  about  differ.  They  have  previously  been  referred  to,  and  the 
indications  for  treatment  are  obvious.  One  can  infer  from  the  state 
of  the  saliva  the  condition  of  the  intestinal  canal,  a  matter  of  the 
highest  importance  practically.  There  is  no  doubt  that,  except  pos- 
sibly in  diabetes,  when  there  is  diminished  saliva,  there  is  also  dimin- 
ished gastro-intestinal  secretion.  Such  diminution  is  followed  by  loss 
of  appetite  and  impairment  of  digestion.  The  indication  is  at  once  to 
administer  material  that  is  digested  with  the  least  difficulty.  Hence 
liquid  food  and  stimulants  are  to  be  used.  The  dry  and  bare  tongue 
is  of  serious  prognostic  omen  in  all  conditions.  While  it  may  be  due 
to  want  of  saliva  alone,  it  also  occurs  as  a  part  of  the  failure  of  nutrition 
in  hectic  fever,  suppuration,  and  other  conditions.  It  is  an  indication 
for  the  use  of  tonics,  stimulants,  and  liquid  and  highly  nutritious 
food.  The  weak  pulse  does  not  more  surely  tell  of  an  asthenic  ten- 
dency than  the  red,  dry,  and  polished  tongue. 

Movements  of  the  Tongue.  When  the  patient  is  asked  to  put 
out  his  tongue  it  is  done  without  other  movement  thau  that  required 
for  its  ejection.     Interference  with  its  motility  occurs  in  disease,  when 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     475 

the  projection  is  attended  by  abnormal  movement.  It  may  be  tremu- 
lous, as  in  alcoholism  or  in  simple  weakness  alone.  It  may  be  slow 
or  impeded  in  the  stages  of  various  paralyses.  It  is  tremulous  and 
the  seat  of  fibrillar  contractions  in  general  paralysis.  It  cannot  be 
projected  at  all  in  glosso-labial  paralysis  ;  it  can  be  projected,  but 
with  difficulty,  and  may  have  to  be  aided  by  the  finger  in  general 
paralysis  and  diphtheritic  paralysis,  progressive  muscular  atrophy 
and  hemiplegia,  because  the  paralysis  is  only  partial.  The  tongue 
points  to  the  paralyzed  side  of  the  body  in  hemiplegia  in  which  the 
face  is  involved. 

Angina  Ludovicl  Angina  Ludovici  is  characterized  by  slight 
inflammatory  congestion  of  the  throat  out  of  proportion  to  the  symp- 
toms of  the  inflammation  in  the  external  structures.  Woodeny  indu- 
ration of  the  connective  tissue,  which  will  not  receive  impressions, 
spreading  of  this  induration  instead  of  fading  off,  so  that  it  is  bound 
sharply  by  unaffected  cellular  tissue  ;  the  induration  may  extend  from 
the  rami  of  the  jaws  to  the  face.  With  this  there  is  a  hard  swelling 
in  the  tongue  and  along  the  interior  lower  jaw,  causing  thickening  of 
the  floor  of  the  mouth.  This  is  observed  by  palpation  with  the  finger 
in  the  mouth.  The  glands  are  not  affected.  For  a  long  time  the  nature 
of  this  affection  was  not  known.  It  is  now  believed  to  be  due  to 
actinomyces  (see  Parker,  Lancet,  1879,  and  Anderson,  Transactions  of 
Medico-  Chir  urgical  Society,  1891). 

The  Fauces  and  Pharynx. 

The  passageway  between  the  mouth  and  the  respiratory  passages  is 
lined  with  mucous  membrane,  which  is  subject  to  diseases  to  which 
they  are  liable.  The  symptoms  thereof  are  similar  to  the  symptoms 
of  mucous-membrane  inflammation  elsewhere.  The  large  muscles  of 
the  pharynx  which  aid  in  deglutition  are  subject  to  affections  which 
belong  to  muscular  tissue  generally,  hence  rheumatic  inflammation  and 
loss  of  power  of  muscle,  or  paralysis,  occurs.  Paralysis  of  the  phar- 
ynx has  not  the  same  diagnostic  significance  of  central  lesions  as  paral- 
ysis of  other  structures,  such  as  parts  of  the  larynx.  This  is  due  to 
the  fact  that  the  nerve-supply  of  the  pharynx  is  derived  from  a  nerve 
(glosso-pharyngeal)  which  supplies  other  structures,  paralysis  of  which 
is  more  evident  than  pharyngeal  paralysis,  more  readily  ascertained, 
and  which  causes  more  pronounced  symptoms  (see  Cerebral  Nerves). 
From  its  adjacent  situation  the  pharynx  is  particularly  liable  to  infec- 
tion from  micro-organisms.  The  infection  may  extend  from  the 
mouth,  or  above  from  the  nares,  or  the  micro-organisms  may  affect  it 
primarily. 

The  fauces  and  pharynx  may  be  the  seat  of  morbid  processes  which 
occur  secondarily  to  diseases  in  other  portions  of  the  body  with  a 
moderate  degree  of  frequency.  Inflammations  of  the  mucous  mem- 
brane of  the  pharynx  are  of  rheumatic  or  gouty  origin  in  a  large  num- 
ber of  cases.  Indeed,  gouty  inflammation  of  the  pharynx  seems  to 
be  more  common  than  gouty  inflammations  of  mucous  membranes  in 
other  situations.     The  large  majority  of  subacute  or  chronic  pharyn- 


476  SPECIAL  DIAGNOSIS. 

geal  inflammations  are  secondary  to  dyspepsia.  They  also  occur  from 
extension  of  the  disease  from  cavities  related  to  the  pharynx. 

Affections  of  the  tonsils  are  usually  more  common  in  rheumatic 
states,  and  bear  some  relationship  to  the  rheumatic  diathesis.  Inflam- 
mation of  the  tonsils  may  follow  acute  rheumatism  or  may  alternate 
with  it.  A  patient  who  is  predisposed  to  rheumatism  may  at  one  sea- 
son have  tonsillar  inflammation,  at  another  rheumatism.  The  writer 
has  seen  tonsillitis  immediately  followed  by  rheumatism,  and  then  the 
latter  replaced  by  the  former. 

Apart  from  what  has  just  been  said,  diseases  of  the  pharynx  bear 
but  little,  if  any,  diagnostic  relationship  to  disease  elsewhere.  "While 
there  may  be  cyanosis  of  the  mucous  membrane,  or  tuberculous  ulcer- 
ation, or  other  changes  which  we  have  noted,  the  signs  of  the  primary 
disease  are  so  much  more  marked  that  we  need  not  rely  upon  the 
appearance  of  the  pharynx  or  symptoms  of  pharyngeal  disease  for 
diagnostic  purposes.  The  only  general  affection  which  may  be  diag- 
nosticated from  the  appearance  of  the  pharynx  alone  is  measles.  In 
obscure  cases  of  sudden  fever,  with  nasal  catarrh,  the  appearance  of 
the  eruption  in  the  situation  previously  indicated  may  lead  to  the  recog- 
nition of  measles  when  the  external  eruption  is  not  apparent.  For 
the  purposes  of  the  therapeutist  it  should  be  borne  in  mind  that  symp- 
toms referable  to  the  pharynx  are  very  frequently  due  to  disease  in  the 
nares,  particularly  in  that  portion  of  the  pharynx  which  is  not  open 
to  direct  inspection — the  naso-pharynx. 

The  general  symptoms  of  pharyngeal  disease  are  not  marked,  except 
in  diphtheria,  in  erysipelas,  in  retro-pharyngeal  abscess,  and  in  affec- 
tions of  the  tonsils.  In  the  latter  the  general  symptoms  appear  to  be 
out  of  proportion  to  the  local  process.  The  high  fever,  the  intense 
headache  and  backache,  and  rapid  pulse,  seem  to  point  to  a  process 
which  in  extent  and  severity  should  far  surpass  that  which  occurs  in 
the  tonsils. 

As  a  passageway  or  channel,  affections  of  the  pharynx  are  liable 
to  obstruct  it,  causing  symptoms  of  occlusion.  As  a  channel  for  the 
passage  of  air,  obstruction  in  the  pharynx  will  lead  to  dyspnoea.  In 
addition  to  its  function  as  a  simple  channel,  the  pharynx  is  concerned 
in  the  act  of  deglutition.  When,  therefore,  there  is  obstruction  of 
the  pharynx,  deglutition  is  made  difficult,  or  may  even  become  impos- 
sible. 

Attention  cannot  be  too  strongly  directed  to  the  investigation  of  the 
naso-pharynx  in  children  who  are  poorly  developed  physically  and 
mentally,  and  who  present  appearances  that,  to  the  practised  eye,  are 
most  familiar.  The  experienced  observer  will  at  once  judge,  and 
judge  correctly,  that  this  combination  of  symptoms  is  due  to  disease 
in  the  naso-pharynx.  Reference  must  be  made  to  the  remarks  on 
adenoid  vegetations  of  the  naso-pharynx,  but  it  is  proper  to  state  here 
the  relationship  and  the  importance  of  investigating  the  structures  in 
the  class  of  cases  just  indicated. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  CFSOPHAGUS.     477 

The  Objective  Symptoms. 

Examination  of  the  Fauces.  Inspection.  For  this  purpose 
examination  is  made  by  the  unaided  eye,  illuminating  as  in  laryngeal 
diseases.  The  difficulties  of  examination  arise  from  the  tongue  and 
the  uvula.  The  mouth  should  be  opened  as  wide  as  is  consistent  with 
comfort  and  in  an  unrestrained  manner.  The  tongue  is  pressed  out  of 
the  way  by  the  use  of  a  tongue-depressor.  In  many  cases,  however, 
even  with  the  tongue-depressor,  the  tongue  muscles  will  contract  and 
the  organ  bunch  up  in  the  mouth.  Moderate,  quiet,  full  breathing, 
gently  opening  the  mouth  as  the  deeper  inspirations  are  made,  causes 
the  tongue  to  be  relaxed  and  lie  in  the  bottom  of  the  mouth,  and  at  the 
same  time  elevates  the  uvula.  At  the  time  of  the  full  breath  the  part 
may  be  inspected  throughout.  Sometimes  the  fauces  can  be  examined 
if  the  tongue  is  protruded  and  held  with  a  soft  napkin  between  the 
finger  and  thumb,  by  the  patient.  In  the  fauces  the  tonsils  and  uvula 
are  to  be  observed,  following  out  the  routine  method  of  ascertaining 
all  facts.  Attention  is  then  paid  to  the  posterior  wall  of  the  pharynx 
with  the  same  object  in  view. 

Method.  In  examining  the  fauces  and  pharynx  observation  is  made 
of  the  color  of  the  parts,  the  appearance  of  the  mucous  membrane  and 
its  glands,  the  appearance  and  position  of  the  uvula,  the  size  of  the 
tonsils,  the  character  of  the  secretions  on  the  pharynx,  and  the  pres- 
ence or  absence  of  swellings  and  abnormal  exudations. 

Color.  The  color  of  the  mucous  membranes  is  generally  dark  red. 
The  color  is  increased  in  intensity  in  acute  inflammations  of  the 
pharynx,  whether  primary  or  secondary.  In  the  acute  forms  of  phar- 
yngitis the  color  is  bright  red.  In  cases  of  heart  disease,  when  there 
is  cyanosis  the  veins  are  congested.  In  obstruction  of  the  superior 
vena  cava  by  tumor  there  is  a  cyanotic  hue  of  the  surface  of  the 
pharynx.  The  capillary  vessels  may  pulsate  in  aortic  regurgitation. 
Bleeding-points  may  be  seen  over  the  surface  of  the  pharynx,  the 
discharges  of  blood  from  which  may  simulate  pulmonary  hemorrhage. 
The  blood  may  be  swallowed  and  then  vomited,  and  hence  gastric 
hemorrhage  is  simulated.  When  the  hemorrhage  occurs  at  night  it  is 
seen  on  the  pillow  as  yellowish  stains.  It  is  often  due  to  adenoid 
vegetations  in  the  naso- pharynx. 

On  examination  of  the  posterior  wall  of  the  healthy  pharynx  little 
elevations  due  to  glands  are  seen  upon  its  surface,  and  moderate-sized 
vessels  are  seen  coursing  through  the  mucous  membrane. 

Eruptions.  Eruptions  may  be  observed  in  the  pharynx  in  some 
of  the  specific  fevers.  Thus,  in  measles,  the  appearance  of  the  rash 
on  the  pharynx  and  on  the  soft  palate  may  be  observed  before  the 
development  of  the  rash  on  the  surface  of  the  skin.  The  eruption  of 
scarlatina  is  also  seen  in  the  pharynx,  and  the  papules  and  pustules  of 
variola  are  frequently  observed  in  that*aft'ection. 

The  Tonsils.  The  tonsils  are  situated  at  the  sides  of  the  pharynx 
between  the  anterior  and  posterior  folds  of  the  palate.  They  are  path- 
ologically of  much  importance.  They  are  made  up  of  glandular  struc- 
ture arranged  in  follicles  and  held  together  by  connective  tissue.     The 


478  SPECIAL  DIAGNOSIS. 

crypts  of  the  follicles  open  on  the  surface,  and  in  disease  are  visible. 
The  tonsils  are  small  bodies,  not  larger  than  a  filbert  in  the  adult. 
Their  entire  surface  can  be  seen  by  ordinary  inspection.  If  enlarged, 
the  posterior  surface  cannot  be  seen,  although  a  larger  view  may  be 
obtained  by  causing  the  patient  to  gag  or  retch,  during  which  they  are 
brought  forward  to  the  light.  The  diseases  of  the  tonsils  have  nothing 
to  do  with  their  function  as  far  as  known.  The  tissue  and  gland  folli- 
cles are  liable  to  inflammations,  which  may  be  bacterial  or  may  be  the 
result  of  rheumatism.  The  tonsils  become  enlarged;  the  swelling  takes 
place  rapidly  in  the  acute  forms.  They  may  be  simply  enlarged  and 
the  covering  membrane  intensely  red.  In  other  forms  of  inflammation 
the  surface  may  be  dotted  over  with  white  points,  due  to  exudation 
from  the  follicles;  these  may  be  covered  with  a  white  or  grayish  mem- 
brane, which  is  removed  with  difficulty,  leaving  an  abraded  surface 
underneath.  Repeated  attacks  of  inflammation  cause  chronic  enlarge- 
ment of  the  tonsils.  They  are  enlarged  sometimes  to  a  great  degree, 
filling  almost  entirely  the  lumen  of  the  fauces;  The  surface  is  irreg- 
ular, and  may  be  scarred.  The  mouths  of  the  follicles  may  be  dilated. 
By  virtue  of  their  position,  enlarged  tonsils  from  any  cause  are  the 
source  of  dyspnoea  and  dysphagia.  The  tonsils  may  be  the  seat  of  sar- 
coma and  tuberculosis. 

The  Uvula.  In  health  it  hangs  midway  from  the  palate.  It 
varies  in  shape  from  congenital  causes,  and  may  be  elongated  on  account 
of  disease.  This  particularly  takes  place  if  there  has  been  hawking  or 
coughing  on  account  of  chronic  nasal  catarrh.  When  elongated  it  is 
pointed  and  may  extend  almost  to  the  base  of  the  tongue.  The  uvula 
may  be  swollen  and  oedematous.  The  oedema  is  usually  associated 
with  subcutaneous  oedema  in  the  course  of  Bright' s  disease.  It  may 
occur  in  debility.  In  both  conditions  it  may  become  so  enlarged  as 
to  interfere  with  swallowing  and  breathing.  In  some  cases  of  pharyn- 
gitis the  uvula  is  the  seat  of  intense  inflammation  and  great  oedema. 
In  addition  to  the  constant  cough  which  it  causes  there  may  be  dysp- 
noea and  repeated  attacks  of  strangulation. 

Hemorrhagic  infarcts  may  take  place  in  the  uvula.  In  two  instances 
under  the  writer's  care  the  intense  infarction  led  to  sloughing,  and  in 
one  the  uvula  was  swallowed. 

Ulceration.  Follicular  Ulceration.  Small  superficial  ulcers  corre- 
sponding to  the  follicles  may  be  seen  over  the  posterior  wall  of  the 
pharynx.  They  occur  in  chronic  catarrh,  and  are  due  to  the  inflam- 
mation of  the  follicles.  In  addition,  ulcers  secondary  to  infectious 
processes  are  sometimes  seen,  as  in  typhoid  fever.  In  syphilisrm  the 
secondary  stage,  small,  shallow  ulcers  are  seen  on  the  posterior  wall 
of  the  pharynx.  They  do  not  cause  pain.  Mucous  patches  are 
observed  at  the  same  time,  not  only  on  the  pharynx,  but  also  in  the 
mouth.  In  the  tertiary  stage  deep  ulcers,  followed  by  scars,  are  seen 
on  the  posterior  wall  of  the  pharynx.  Although  the  absence  of  pain 
renders  it  probable  that  they  are  of  syphilitic  origin,  nevertheless  the 
history  of  infection  and  of  the  primary  lesion,  and  the  evidence  of 
the  disease  in  other  structures  ought  to  be  secured  before  a  diagnosis  is 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     479 

fully  established.  In  the  tertiary  forms  it  may  be  necessary  to  resort 
to  the  therapeutic  test. 

Tuberculous  ulcers  are  irregular  in  shape,  and  the  floor  grayish. 
They  are  seen  in  tuberculosis  in  its  later  stages.  They  are  the  source 
of  extreme  pain.  There  is  usually  ulceration  in  the  larynx  at  the 
same  time,  and,  in  extremely  rare  cases,  tuberculous  ulceration  of  the 
tousils.  In  a  patient,  a  lad  of  sixteen  years,  under  the  writer's  care, 
the  large  tonsils  were  of  a  honeycombed  appearance  on  account  of  the 
grayish,  irregular  ulceration.  Deglutition  was  absolutely  impossible 
on  account  of  the  pain,  and  the  young  man  died  of  starvation.  In 
tuberculous  ulceration,  after  the  application  of  cocaine,  a  portion  may 
be  scraped  off,  and  a  microscopical  examination  will  show  the  presence 
of  bacilli. 

Cancer  of  the  pharynx  is  rare,  and  is  usually  secondary,  the  disease 
having  spread  from  other  situations. 

Exudations  on  the  tonsils  are  due  to  inflammation  of  the  follicles, 
to  diphtheria,  to  the  pseudo  diphtheritic  inflammation  which  attends 
scarlatina,  or  which  arises  secondarily  to  other  infectious  debilitating 
diseases,  and  to  thrush.  On  the  pharynx  the  exudation  may  be  due 
to  diphtheria,  to  pseudo-diphtheria,  or  to  thrush.  The  method  of  dis- 
tinguishing the  various  forms  will  be  considered  in  the  articles  on  the 
respective  affections.  In  diphtheria  the  membrane  is  made  up  of 
fibrin  arranged  in  a  network,  in  the  meshes  of  which  epithelium,  blood- 
and  pus-corpuscles  and  micro-organisms  are  found.  When  removed, 
hemorrhagic  abrasions  and  raw  purulent  inflammation  remain.  Two 
forms  of  bacilli  are  found  in  the  membrane;  the  pseudo-diphther- 
itic bacillus  or  streptococcus,  and  the  true,  or  Loffler's  bacillus  (see 
Bacteriology).  The  Loftier  bacillus  is  best  detected  by  cultivations. 
After  the  membrane  is  removed  and  washed  in  a  2  per  cent,  solution 
of  boric  acid,  it  is  cultivated  in  blood-serum. 

The  pseudo-diphtheritic  bacillus  likewise  grows,  but  its  appearances 
are  different. 

Anaesthesia.  Some  of  the  results  of  inspection  may  be  confirmed 
by  means  of  the  probe,  and  alterations  in  the  sensibility  of  the 
pharynx  may  be  detected.  Sensations  may  be  absent  in  the  whole 
posterior  wall  of  the  pharynx.  Loss  of  sensation  may  occur  in  hys- 
teria, in  bulbar  paralysis,  and  in  diphtheritic  paralysis.  On  the  other 
hand,  there  may  be  an  apparent  hyperossthesia.  In  some  individuals 
the  pharynx  is  particularly  sensitive  to  the  presence  of  foreign  bodies, 
as  inflammatory  exudates,  and  may  resent  their  presence  by  sudden 
coughing  and  retching.  Inflammations  increase  the  hyperesthesia  of 
the  pharynx.     The  condition  is  sometimes  observed  in  hysteria. 

The  cervical  glands.  The  pharynx  is  in  such  intimate  relation  with 
the  large  lymphatic  glands  in  the  neck  that  diseases  of  the  former  are 
frequently  attended  by  enlargement  of  the  latter.  The  glands  at  the 
angle  of  the  jaw  are  increased  in  size.  The  glands  extending  along 
the  vessels  of  the  neck  may  also  be  enlarged.  In  cases,  therefore,  of 
enlargement  of  the  glands  in  this  situation,  it  is  absolutely  essential 
to  examine  the  fauces  and  pharynx. 

Leptotkri.v  of  the  Tonsils.     In  healthy  persons  the  plugs  which  block 


480  SPECIAL  DIAGNOSIS. 

the  tonsillar  crypts  are  found  to  be  made  up  of  cells  and  segmented 
fungi.  The  latter  stain  bluish-red  with  iodo-potassic  iodide  solution. 
Sometimes  the  micro-organisms  extend  beyond  the  follicles,  covering 
the  surface  of  the  tonsils  with  patches  of  various  size.  They  are  thus 
seen  in  follicular  tonsillitis. 

Subjective  Symptoms. 

Pain.  In  affections  of  the  fauces  and  pharynx  pain  is  one  of  the 
most  common  subjective  symptoms.  It  is  due  to  the  fact  that  the 
functional  acts  of  the  pharynx  require  movement  of  all  the  structures. 
When  they  are  the  seat  of  inflammation,  or  ulceration,  the  movement 
excites  pain.  It  is,  therefore,  a  symptom  of  great  severity  in  inflam- 
mation of  the  tonsils  and  pharynx,  of  rheumatism  of  the  muscular 
structure  of  the  pharynx,  and  of  tuberculosis  and  cancerous  ulceration. 
Pain  in  the  pharynx  is  a  frequent  accompaniment  of  post-nasal  inflam- 
mations, although  the  pharynx  itself  is  not  affected. 

Dryness.  Dryness  of  the  fauces,  with  a  tickling  sensation  and  a 
more  or  less  constant  desire  to  hawk,  occurs  in  pharyngitis.  Hawk- 
ing, however,  is  not  a  symptom  of  disease  of  the  pharynx  alone.  It 
may  also  be  due  to  disease  in  the  posterior  nares. 

The  Odor  of  the  Breath.  In  follicular  tonsillitis  the  breath 
has  a  peculiar  odor.  This  is  more  marked  in  the  milder  forms  of 
inflammation,  with  retention  of  the  secretion  of  the  glands.  The 
odor  is  intense  and  foetid.  In  cancer  and  syphilis  there  is  also  a  foetor 
of  the  breath.  The  fcetor  may  be  of  diagnostic  significance  in  distin- 
guishing cancer  from  tuberculosis. 

Dysphagia.  The  symptom  varies  in  degree  from  slight  difficulty 
in  swallowing  to  complete  prevention  of  the  act.  Any  disease  which 
occludes  the  passageway  causes  dysphagia  ;  pain  is  also  a  cause.  It 
is,  therefore,  present  in  all  painful  affections  of  the  pharynx.  Dysp- 
noea is  seen  in  tumors,  in  inflammation  of  the  tonsils,  in  the  rare  form 
of  erysipelas  of  the  pharynx,  and  in  retropharyngeal  abscess.  It 
occurs  from  occlusion  of  the  passages,  and  is  more  marked  in  retro- 
pharyngeal abscess  and  erysipelas  than  in  other  conditions.  In  cer- 
tain forms  of  abscess  of  the  tonsils  it  may  be  very  extreme. 

iSpanm  of  the  pharynx  is  a  subjective  symptom  complained  of  in  some 
cases  of  pharyngitis.  The  degree  of  spasm  or  the  amount  of  choking 
sensation  is  largely  dependent  upon  the  neurotic  constitution  of  the 
individual.  It  may  be  extreme  when  only  a  moderate  amount  of 
inflammation  is  present.  It  is  seen  in  the  most  aggravated  form  in 
hydrophobia. 

Tonsillitis. 

Acute  inflammation  of  the  tonsils  may  be  confined  to  the  follicles, 
to  which  the  term  follicular  tonsillitis  is  applied,  or  it  may  be  lim- 
ited to  the  mucous  membrane,  when  it  is  known  as  catarrhal  or  erythe- 
matous tonsillitis.  If  with  the  catarrhal  inflammations  vesicles  appear 
on  the  mucous  membrane  of  the  surface,  the  term  herpetic  tonsillitis  is 
used.  When  the  inflammation  extends  to  the  stroma  of  the  glands  it 
goes  on  to  suppuration.     It  is  characteristic  of  all  forms  of  acute  ton- 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     481 

sillitis  to  recur  frequently  in  the  same  subject.  The  relationship  to 
rheumatism  has  been  spoken  of.  This  relationship  applies  to  both  the 
acute  and  the  suppurative  forms.  The  various  forms  of  tonsillitis 
occur  at  any  age,  although  it  is  least  common  under  ten  years  of  age  ; 
the  suppurative  form  occurs  most  frequently  in  adolescence.  Tonsillitis 
occurs  in  both  sexes.  It  may  follow  exposure  to  wet  and  cold,  although 
patients  who  are  subject  to  the  attacks  bear  exposure,  unless  they  are  at 
the  same  time  unduly  fatigued.  The  follicular  form  of  tonsillitis  is  so 
frequently  associated  with  bad  drainage  or  other  unhygienic  conditions 
as  to  make  it  probable  that  noxious  emanations  act  as  an  exciting  cause. 
Several  persons  of  the  same  family  may  be  affected  at  one  time,  so 
that  it  is  often  difficult  to  distinguish  the  cases  from  diphtheria.  The 
disease,  however,  is  not  contagious.  Persons  brought  in  contact  with 
the  family,  but  who  do  not  reside  in  the  same  house,  escape  the  disease. 
This  applies  as  well  to  children,  who  would,  if  the  cases  were  diph- 
theritic, be  most  liable  to  become  infected.  The  disease  occurs  more 
commonly  in  the  spring  than  in  any  other  season  of  the  year,  more 
especially  iu  cold  and  wet  seasons. 

Symptoms.  In  follicular  tonsillitis,  with  or  without  a  chill,  but 
always  with  chilly  sensations,  the  temperature  rises  rapidly  to  a  great 
height.  The  subjective  sensation  of  fever  is  very  quickly  noticeable  to 
the  patient,  and  is  generally  more  pronounced  than  in  other  affections. 
With  the  chill  and  during  the  rise  of  temperature  there  are  some  frontal 
headache  and  severe  pain  in  the  back  and  limbs  The  pain  in  the  back 
is  most  excruciating.  In  a  short  time  the  patient  complains  of  pain 
in  the  throat.  Swallowing  is  difficult,  and  there  is  a  sense  of  fulness. 
The  throat  is  dry  and  burning.  On  examination  the  tonsils  are  found 
to  be  swollen,  and  a  yellowish-white  exudation  is  seen  on  the  crypts.  In 
twenty-four  hours  the  points  may  coalesce  to  form  a  patch.  The  glands 
expand  slightly,  and  may  extend  only  slightly  beyond  the  arches,  or, 
in  younger  subjects,  one-quarter  of  the  way  into  the  lumen  of  the 
fauces.  Sometimes  one  gland  is  affected  before  the  other.  The  diffi- 
culty in  deglutition  increases  and  the  voice  becomes  nasal.  There  is 
usually  some  enlargement  of  the  cervical  glands.  The  general  symp- 
toms continue  for  forty-eight  hours,  the  temperature  remains  at  105°, 
and  the  pulse  is  very  rapid.  After  the  first  twenty-four  hours  the 
pain  in  the  back  lessens.  The  tongue  is  coated;  the  breath  is  heavy. 
The  urine  is  loaded  with  urates.  At  the  end  of  the  fifth  day  the  fever, 
which  subsides  gradually,  lias  disappeared.  The  local  symptoms, 
however,  may  remain  longer;  that  is,  the  tonsils  are  still  enlarged  aud 
the  exudation  disappears  slowly.  Sometimes  the  prostration  and 
general  symptoms  are  very  severe,  so  that  after  the  fever  has  subsided 
convalescence  may  be  very  slow. 

Albuminuria,  due  in  all  probability  to  the  fever,  frequently  occurs; 
in  some  cases,  undoubtedly,  acute  nephritis  attends  the  attack  and 
retards  the  convalescence.  In  a  case  under  the  writer's  care  the  patient 
first  had  acute  rheumatism  ;  this  was  replaced  by  a  severe  attack  of 
tonsillitis,  during  which  albumin,  blood,  and  granular  casts  were  found 
in  the  urine.       The  swelling  of  the  tonsils  subsided  in  due  course,  but 

31 


482  SPECIAL  DIAGNOSIS. 

the  Bright's  disease  continued  a  long  period,  finall)r  ending,  however, 
in  complete  recovery. 

In  herpetic  tonsillitis  the  severe  pain  and  intense  general  symptoms 
are  out  of  proportion  to  the  local  lesion.  In  suppurative  tonsillitis  the 
constitutional  disturbance  is  also  very  great.  The  temperature  rises 
high,  104°  to  105°,  and  the  pulse  is  very  rapid,  from  110  to  130  in 
the  adult.  The  inflammation  usually  begins  in  one  tonsil  and  the 
other  is  involved  later.  The  tonsils  at  first  are  enlarged  and  firm  and 
very  red.  There  is  swelling  of  the  surrounding  tissues.  In  twenty- 
four  hours  deglutition  becomes  almost  impossible,  and  there  is  saliva- 
tion. At  the  end  of  forty-eight  hours  the  patient  presents  a  striking 
appearance.  The  glands  of  the  neck  are  enlarged,  the  patient  is  unable 
to  open  his  mouth,  the  voice  is  nasal  or  almost  suppressed;  there  is 
dribbling  of  saliva  from  the  mouth.  The  face  may  have  a  dusky  hue 
in  spite  of  the  capillary  congestion  due  to  the  fever.  There  is  con- 
stant desire  to  discharge  saliva  and  accumulated  secretions  from  the 
back  part  of  the  mouth.  The  patient  cannot  lie  down.  The  pain  is 
extreme,  and  is  aggravated  by  swallowing.  It  is  sometimes  of  a 
throbbing  character  and  often  shoots  to  the  ears.  Indeed,  the  earache 
may  be  chiefly  complained  of.  The  patient  does  not  take  food,  and 
exhaustion  soon  ensues.  During  the  twenty-four  hours  before  rupture 
takes  place  the  previously  reddened  face  becomes  blanched  from  ex- 
haustion. The  fever  is  continuous  during  this  time,  with  great  rapidity 
of  the  pulse.  The  patient  may  be  delirious.  Sometimes  the  delirium 
is  marked  and  the  patient  resists  efforts  to  keep  him  in  bed. 

The  suffering  is  out  of  proportion  to  the  danger  of  the  case.  About 
the  fourth  or  fifth  day  suppuration  is  over,  and  if  the  finger  can  be 
inserted  into  the  mouth  between  the  almost  closed  teeth,  fluctuation  is 
detected.  In  cases  in  which  the  mouth  is  opened  a  little  more  freely, 
in  addition  to  the  swelling  of  the  tonsils  below  the  arches,  marked 
swelling  and  projection  forward  of  the  half-arches  may  be  seen.  The 
fluctuation  may  be  detected  through  the  anterior  fold  of  the  palate, 
and,  if  lancing  is  to  be  performed,  the  pus  can  only  be  reached  through 
this  structure.  After  spontaneous  rupture,  which  usually  takes  place 
upward  into  the  mouth,  instant  relief  is  experienced.  Rupture  may 
take  place  into  the  pharynx  and  cause  suffocation  from  entrance  of  pus 
into  the  larynx.  In  rare  cases  it  has  opened  into  the  carotid  artery, 
causing  instant  death  from  hemorrhage. 

Diagnosis.  The  diagnostic  features  of  acute  tonsillitis  are  the  sud- 
den high  fever,  severe  backache  and  headache,  pain  in  the  throat,  and 
albuminuria.  The  characteristic  appearance  of  the  face,  the-saliva- 
tion  and  pain,  with  suppressed  voice  and  difficult  deglutition,  should 
not  cause  it  to  be  confounded  with  trismus  or  tetanus.  In  both  the 
jaws  are  closed.  It  must  not  be  confounded  with  smallpox,  which  it 
resembles  during  the  first  twenty-four  hours. 

Cases  of  follicular  tonsillitis  are  frequently  mistaken  for  diphtheria. 
The  inflammation  in  tonsillitis  is  limited  to  the  glands,  on  which  are 
patches  of  a  yellowish  gray  color,  easily  removed  without  leaving 
bleeding  surfaces.  In  diphtheria  the  membrane  is  of  an  ashy-gray 
color,  not  in  points  or  small  patches,  or  separated   by  red  tonsillar 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     483 

tissue;  it  extends  to  the  pillars  of  the  fauces,  and  may  appear  on  the 
uvula.  There  are,  nevertheless,  many  cases  which  are  doubtful,  and 
bacteriological  diagnosis  must  be  resorted  to  (see  Bacteriological  Exam- 
ination) ;  a  history  of  exposure  sometimes  helps  us  to  arrive  at  a  con- 
clusion. The  cases  that  particularly  increase  our  anxiety  are  those 
of  adults  who  are  subject  to  attacks  of  follicular  tonsillitis.  In  the 
grave  and  extensive  forms  of  diphtheria  with  asthenic  symptoms  the 
diagnosis  is  not  difficult. 

Enlargement  of  the  Tonsils. 

Chronic  Tonsillitis.  The  tonsils  may  be  enlarged  on  account  of 
repeated  attacks  of  acute  inflammation,  or  from  chronic  inflammation. 
They  do  not  appear  to  cause  serious  symptoms  unless  associated  with 
adenoid  vegetations  in  the  naso-pharynx.  They  may  interfere  with 
hearing,  however,  and  cause  snoring  at  night.  A  fcetor  of  the  breath 
may  be  noted,  particularly  if  the  secretion  lodges  in  the  crypts.  This 
may  be  recognized  by  its  characteristic  yellowish  color  and  by  its  odor  on 
removal.  The  enlarged  tonsils  are  irregular  in  contour  and  on  the  surface. 

Foreign  bodies  in  the  tonsils  are  not  of  common  occurrence.  They 
give  rise  to  local  symptoms,  as  the  sensation  of  the  presence  of  a  mass 
causing  repeated  efforts  at  swallowing.  If  calculi  are  present,  the 
patient  may  complain  of  a  rough  body.  The  calculi  and  rough  sensa- 
tions follow  frequent  attacks  of  quinsy.  Hydatids  are  sometimes 
located  in  the  tonsils. 

Adenoid  Vegetations  of  the  Naso-pharynx.  Adenoid  vegeta- 
tion causes  more  or  less  obstruction  in  the  naso-pharynx.  The  symp- 
toms may  be  classed  as  primary  and  secondary.  The  former  are  local, 
and  due  to  the  foreign  substance,  per  se ;  the  latter  are  local  and 
general.     The  former  are  catarrhal  ;  the  latter  the  result  of  stenosis. 

Local  Symptoms.  In  a  large  number  of  cases  there  is  discharge  from 
the  nose.  This  may  be  muco-purulent,  or  be  associated  with  crusts. 
If  the  discharge  is  not  constant,  the  child  is  subject  to  coryza  and 
discharge  on  the  slightest  provocation.  With  or  without  the  chronic 
purulent  nasal  discharge  mucus  and  blood  may  be  passed  at  night  and 
found  on  the  pillow  in  the  morning. 

The  hearing  is  frequently  impaired.  There  may  be  simply  dulness 
of  hearing,  or  it  may  amount  to  marked  deafness,  either  because  of 
pressure  of  the  adenoid  vegetations,  or  extension  of  secondary  inflam- 
mation to  the  Eustachian  tubes;  the  senses  of  taste  and  smell  are  often 
much  impaired.  There  is  increase  in  the  secretion  of  pharyngeal 
mucus,  which  in  older  persons  causes  difficult  expectoration. 

Rhinoscopic  Examination.  The  floor  -of  the  pharynx  is  covered 
with  rounded  or  villous  projections,  often  concealing  the  posterior 
nares.  Rarely  the  villi  may  be  seen  projecting  below  the  soft  palate. 
In  children  the  examination  is  difficult,  and.  hence  digital  exploration 
must  be  used  after  an  anaesthetic.  The  finger  readily  detects  the  masses, 
which  sometimes  are  soft,  at  other  times  tough  and  of  fibrous  or  car- 
tilaginous consistency. 


484  SPECIAL  DIAGNOSIS. 

Symptoms  of  Stenosis.  The  Mouth.  The  mouth  is  kept  open  in 
breathing.  The  lips  are  always  dry  and  may  be  cracked.  They  are 
thickened.      The  dental  arch  is  high  and  narrowed. 

The  Nose.  The  nostrils  are  flattened  laterally.  Rarely  they  may 
be  depressed.  In  one  instance,  which  the  writer  saw  with  Dr.  Harri- 
son Alien,  the  exterior  of  the  nose  suggested  inherited  syphilis,  all  the 
more  because  of  our  knowledge  of  the  possible  presence  of  the  disease. 
There  were  no  other  evidences  of  hereditary  syphilis  in  the  child  or 
in  any  members  of  his  family. 

The  Voice.  It  is  thick  and  muffled,  becoming  indistinct  upon  the 
occurrence  of  slight  cold.  The  expression  of  the  face  is  characteristic. 
It  is  dull  and  stupid,  and  may  be  drawn. 

Mental  and  Nervous  Symptoms.  Headache,  listlessness,  and  indis- 
position for  mental  exertion  are  marked.  The  patients  are  usually 
backward  in  their  studies  and  are  unable  to  fix  their  attention  for  any 
length  of  time  upon  any  subject.  Aprosexia  is  the  term  applied  to 
this  condition.  The  child  is  forgetful  and  cannot  study  without  effort. 
Choreiform  spasm  of  the  face  occurs  in  connection  with  it.  Enuresis 
is  a  frequent  associate  symptom.  The  child  is  subject  to  frequent 
attacks  of  indigestion.  I  have  seen  the  following  occur  in  many  cases  : 
Prior  to  operation  the  child  had  an  abnormally  poor  appetite  and  was 
subject  to  frequent  attacks  of  indigestion,  characterized  by  vomiting, 
with  fever.  After  the  operation  the  appetite  improved  and  continued 
good,  and  the  attacks  of  indigestion  disappeared  entirely.  The  cases 
had  been  under  observation  before  and  after  the  operation  for  a  num- 
ber of  years.  The  indigestion  seems  to  have  been  due  to  the  fact  that, 
owing  to  the  obstruction,  the  child  would  have  to  eat  rapidly  in  order 
to  keep  the  lumen  of  the  mouth  free  for  breathing-purposes.  The 
rapid  eating,  of  course,  prevented  proper  mouth-digestion,  and  hence 
the  occurrence  of  gastric  catarrh. 

Symptoms  from  embarrassed  respiration.  In  addition  to  mouth- 
breathing,  the  patient  snores  at  night,  and  sleep  is  always  disturbed. 
The  respirations  are  irregular,  with  a  pause  between,  followed  by  noisy 
inspirations.  The  difficulty  of  breathing  is  the  cause  of  restlessness, 
and  the  child  will  often  wake  up  in  the  night  with  dyspnoea.  Night- 
restlessness  with  dyspnosa  and  irregular  respiration  should  point,  there- 
fore, to  obstruction  in  the  naso-pharynx. 

The  Appearance  of  the  Chest.  "While  there  is  a  general  lack  of 
physical  development,  the  appearance  of  the  chest  is  most  striking. 
The  cases  have  been  frequently  mistaken  for  rickets,  however  ;  in  this 
country  adenoid  vegetations  are  a  common  cause  of  chest-deformity, 
whereas  in  England  and  on  the  continent  rickets  is  the  most  frequent 
cause.  The  ribs  are  prominent  in  front,  the  sternum  is  angulated 
forward  at  the  manubrio-gladiolar  junction  and  grooved  at  the  gladi- 
olar-xiphoid  junction.  A  saucer-shaped  depression  is  found  at  the 
lower  costal  cartilages.  The  ribs  behind  arc  closely  compressed,  so 
that  the  intercostal  spaces  at  the  lower  part  of  the  chest  are  obliterated. 
The  chicken -breast  appearance  is  most  striking,  with  the  depression 
in  the  lower  portions  of  the  chest.  The  diaphragm  may  be  drawn  in 
during  inspiration  in  the  middle  and  lateral  thoracic  regions. 


DISEASES  OF  JIOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     485 

The  student  cannot  become  too  familiar  with  the  symptoms  and 
signs  of  adenoid  disease  of  the  naso-pharynx.  There  is  no  doubt  that 
in  our  large  cities  this  local  affection  is  of  more  common  occurrence 
and  more  disastrous  in  its  results  than  any  other  that  we  have  to  deal 
with  in  children.  It  may  be  said  that  in  children  in  poor  health, 
ausemic,  with  impaired  digestion,  and  lack  of  muscular  and  physical 
development,  if  the  causes  are  not  due  to  impure  air  and  improper 
diet  or  to  improper  sanitation  generally,  it  is  almost  certain  that  there 
is  disease  of  the  naso-pharynx.  The  writer  has  seen  a  very  large 
number  of  cases  in  recent  years  in  his  practice,  many  of  which  have 
been  operated  on  by  Dr.  Harrison  Allen,  and  he  has  had  the  satisfac- 
tion of  seeing  the  entire  picture  of  the  child  change  after  proper  treat- 
ment. It  may  be  said  in  passing  that  this  change  does  not  take  place 
at  once,  but  after  three  to  twelve  months  the  child  will  be  fully  restored 
in  physique,  if  during  that  time  attention  is  paid  to  proper  exercise 
and  the  development  of  the  chest.  Notwithstanding  all  this,  however, 
the  natural  shape  of  the  chest  and  appearance  of  the  face  are  only 
resumed  gradually. 

Inflammations  of  the  Pharynx. 

Inflammation  of  the  pharynx,  acute  pharyngitis,  or  sore-throat,  fol- 
lows cold  or  exposure,  particularly  after  the  patients  have  been  phys- 
ically depressed  ;  the  inflammation  often  involves  the  tonsils  as  well 
as  the  pharynx.  The  symptoms  are  pain  on  swallowing,  with  dry- 
ness and  a  constant  desire  to  hawk  and  cough  on  account  of  the  tick- 
ling seusation.  There  may  be  slight  laryngitis  and  inflammation  of 
the  Eustachian  tubes,  with  deafness.  Stiffness  of  the  neck  and  enlarge- 
ment of  the  cervical  glands  attend  the  local  inflammation.  The  gen- 
eral symptoms  are  not  marked.  The  attack  is  ushered  in  by  chilliness 
and  slight  fever.  On  examination  the  mucous  membrane  is  seen  to 
be  congested,  dry,  and  glistening,  and  covered  with  sticky  secretions 
in  spots.  The  uvula  may  be  very  much  swollen.  The  acute  inflam- 
mation may  be  associated  with  rheumatism  or  gout.  When  the  sub- 
mucous tissues  are  involved  the  parts  are  more  swollen  and  there  is 
greater  dyspnoea.  The  dysphagia  is  more  marked,  although  the  pain 
is  not  any  greater.  The  larynx  is  always  involved  under  these  cir- 
cumstances.    The  fever  is  higher. 

Phlegmonous  Inflammation.  A  diffused  inflammation  of  this  char- 
acter occurs.  The  writer  saw  one  case  with  dyspnoea,  nervous  symp- 
toms, and  high  temperature,  so  as  to  simulate  severe  pneumonia.  Pneu- 
monia was  thought  to  be  present  because  there  were  congestion  and 
oedema  of  the  lungs.  It  occurred  during  the  prevalence  of  the  recent 
epidemic  of  influenza.  The  disease  began  in  the  pharynx;  the  tissues 
were  swollen  and  infiltrated.  The  early  symptoms  were  pharyngeal. 
The  dysphagia  was  extreme,  and  there  was  an  abundant  muco-purulent 
expectoration,  which  did  not  contain  pneumococei.  Death  took  place 
on  the  ninth  day  from  exhaustion.  The  autopsy  showed  a  high  degree 
of  congestion  of  the  lungs,  and  phlegmonous  inflammation  of  the 
pharynx,  larynx,  and  trachea.      While,  therefore,  the  recognition  of  an 


486  SPECIAL  DIAGNOSIS. 

acute  phlegmonous  inflammation  is  not  difficult,  it  must  not  be  for- 
gotten that  it  is  a  grave  disease  which  may  terminate  in  such  marked 
pulmonary  symptoms  as  to  lead  to  the  suspicion  of  pneumonia. 

Angina  Ludovici  is  an  inflammation  of  the  cellular  tissue  of  the  floor 
of  the  mouth  and  neck.  It  is  probably  a  form  of  actinomycosis.  The 
swelling  is  most  marked  below  the  jaw  of  one  side.  The  symptoms 
are  very  intense  and  both  local  and  general.  There  are  general  septic 
symptoms  at  once.  With  the  swelling  there  are  oedema  and  board-like 
induration.  Redness  and  the  rapid  formation  of  an  abscess  occur 
rarely.  The  throat  is  not  affected.  Death  takes  place  from  reflex 
suffocation  or  in  coma  (see  page  449). 

Rheumatic  Pharyngitis  is  of  short  duration,  without  objective  symp- 
toms. Pain  is  intense,  deglutition  d  ffieult.  The  usual  concomitants 
of  rheumatism  are  present.  It  frequently  gives  place  to  torticollis, 
lumbago,  or  rheumatism  in  some  other  situation. 

Chronic,  Pharyngitis  follows  acute  attacks  and  is  a  frequent  accom- 
paniment of  nasal  catarrh.  It  is  common  in  smokers  and  alcoholic 
subjects;' the  use  of  the  voice  in  loud  tones,  as  by  clergymen,  auction- 
eers, etc.,  is  also  a  cause.  It  is  a  frequent  attendant  upon  indigestion, 
due  probably  to  the  eructations.  The  objective  signs  are  relaxation  of 
the  mucous  membrane,  with  dilatation  of  the  veins.  The  membrane 
is  covered  with  a  thick  secretion,  which  is  dry  and  glistening.  In  the 
granular  form  the  wall  of  the  pharynx  is  covered  with  millet-seed  pro- 
jections and  is  congested.     Tough  mucus  is  seen  in  small  areas. 

Retro-pharyxgeal  Abscess.  The  inflammation  may  begin  in  the 
submucous  connective  tissue,  and  a  retro-pharyngeal  abscess  may  form. 
There  are  high  fever  and  dysphagia  with  stiffness  of  the  neck  and 
enlarged  glands.  On  examination  a  projection  into  the  pharynx  can 
be  seen  or  distinctly  felt  on  the  posterior  wall.  The  disease  may  be 
difficult  of  recognition  in  infants,  in  whom  it  is  possible  to  get  a  good 
view  of  the  pharynx.  On  the  other  hand,  it  may  be  simulated  by 
disease  of  the  cervical  vertebra?,  in  which  there  may  be  stiffness, 
difficulty  in  deglutition,  and  possibly  a  tumor.  It  must  not  be  for- 
gotten that  retro-pharyngeal  abscess  may  result  from  caries  of  the 
cervical  vertebrae.  Iu  children  the  abscess  is  attended  with  dyspnoea 
and  alteration  in  the  voice,  so  that  laryngeal  disease  may  be  suspected. 
I  recall  a  case  of  retro-pharyngeal  abscess  in  which  the  dyspnoea  was 
so  severe  as  to  suggest  croup  ;  in  fact,  preparations  for  tracheotomy 
were  made,  when  sudden  rupture  of  the  abscess  revealed  the  nature  of 
the  disease.  Fortunately  the  child  had  been  kept  in  the  upright  posi- 
tion, so  that  pus  was  discharged  into  the  mouth,  else  suffocation  would 
have  ensued. 

Inflammation  of  the  Parotid  Gland. 

First,  specific  inflammation  or  parotitis  (see  Mumps);  second,  symp- 
tomatic parotitis,  occurs  in  typhoid  fever,  pneumonia,  pyemia,  and 
septicaemia.  The  process  is  intense,  characterized  by  swelling,  redness, 
and  heat  over  the  parotid  gland.  There  are  pain,  and  difficulty  of 
mastication  ;  suppuration  rapidly  ensues.  It  is  thought  to  be  an 
unfavorable  symptom,  but  I  have  seen  two  cases  in  typhoid  fever  get 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     487 

well.  In  a  case  of  septicaemia  it  did  not  advance  to  suppuration. 
Stephen  Paget  has  described  a  symptomatic  inflammation  in  disease  of 
the  abdomen  and  pelvis.  He  collected  101  cases,  50  of  which  were 
due  to  injury,  disease,  or  temporary  derangement  of  the  genital  organs, 
as  by  slight  blows  ;  or  in  females,  to  the  introduction  of  a  pessary. 
It  may  occur  before  the  menstrual  period  or  during  pregnancy.  Sep- 
ticaemia or  pyaemia  does  not  attend  the  process — indeed,  many  of  the 
cases  are  afebrile.  In  .78  cases,  45  suppurated,  and  33  resolved  without 
suppuration. 

Gowers  describes  a  case  of  parotitis  which  occurred  in  the  course 
of  fatal  peripheral  neuritis. 

The  CEsophagus. 

The  oesophagus  is  open  to  all  affections  which  arise  in  mucous  mem- 
branes, although  its  histological  structure,  its  position,  and  its  functions 
protect  it  from  involvement  iu  disease.  Should  morbid  processes  arise, 
the  symptoms  expressive  of  these  processes  are  the  common  symptoms 
of  disease  of  the  mucous  membrane.  But  the  oesophagus  is  a  closed 
tube,  the  function  of  which  is  to  afford  entrance  to  and  to  propel  food 
onward  into  the  stomach.  It  is  subject  to  all  the  affections  common 
to  channels.  Any  disease  of  the  tube  interferes  with  its  function, 
made  evident  by  the  symptom  common  to  all  disorders  of  the  oesoph- 
agus— dysphagia.  As  this  symptom  occupies  a  position  of  such  prom- 
inence in  the  symptomatology  of  diseases  of  this  tube,  it  is  evident 
that  the  diagnosis  of  disease  resolves  itself  into  the  differentiation  of 
all  forms  of  difficulty  of  deglutition. 

Before  beginning  the  discussion  along  the  lines  indicated,  the  sub- 
jective and  objective  symptoms  of  disease  of  the  oesophagus  must  be 
considered. 

The  Subjective  Symptoms.  Pain  is  a  common  symptom  of  dis- 
ease of  the  oesophagus.  In  acute  inflammation  it  is  extreme,  and  is 
complained  of  in  the  neck,  between  the  shoulders,  and  along  the  ver- 
tebra? for  a  short  distance.  Its  character  depends  upon  the  cause. 
Severe  burning  pain,  often  agonizing,  is  due  to  inflammation  from 
burns  or  caustic.  Absence  of  pain  after  the  ingestion  of  caustic  or 
relief  points  to  extreme  corrosive  action  and  gangrene.  Pain  attends 
and  is  a  part  of  the  symptom — dysphagia  (rj.  v.).  Cough  attends  such 
diseases  of  the  oesophagus  as  exert  pressure  upon  the  bronchus,  as 
carcinoma. 

The  Objective  Symptoms.  Stiffness  of  the  neck  is  seen  in  acute 
inflammation  of  the  oesophagus  and  in  peri-oesophageal  abscess  ;  it 
may  also  occur  in  traumatism.  The  expectoration  in  diseases  of  the 
oesophagus  is  characteristic.  It  is  usually  a  glairy  mucus,  often  frothy 
or  viscid.  It  is  not  coughed  up,  but  after  welling  into  the  pharynx 
is  hawked  up.  It  is  abundant  in  acute  and  chronic  inflammation  and 
in  cancer. 

Hemorrhage  ft  om  the  (Esophagus.  Hemorrhage  from  the  oesophagus 
occurs  from  varicosity  of  the  veins  at  the  lower  portion  of  the  gullet. 
It  may  occur  in  old  people,  from  senile  disease  of  the  liver,  kidney, 


488  SPECIAL  DIAGNOSIS. 

and  spleen,  or  at  any  age  in  cirrhosis  of  the  liver.  In  hemorrhage 
from  the  oesophagus  the  blood  is  usually  bright  in  color,  has  not 
been  acted  on  by  an  acid  as  in  hsematemesis,  and  is  not  discharged 
by  vomiting,  although  vomiting  may  occur  after  the  blood  is  poured 
out.  In  a  grave  case  of  purpura  under  the  care  of  the  writer  hemor- 
rhage took  place  from  the  lower  end  of  the  oesophagus.  To  dis- 
tinguish it  from  gastric  hemorrhage  the  stomach  may  be  washed 
out.  If  this  is  done  shortly  after  the  hemorrhage  by  the  introduction 
of  a  soft  bougie,  clear  fluid  will  be  discharged  if  the  gastric  mucous 
membrane  is  intact.  Small  bleedings  from  the  oesophagus  are  usually 
indicative  of  cancer,  especially  if,  in  addition  to  the  hemorrhage,  there 
are  present  the  symptoms  of  occlusion.  Hemorrhage  is  also  seen  in 
foreign  bodies  :  (1)  from  trauma  ;  (2)  from  ulceration.  Emaciation 
is  the  most  characteristic  general  symptom  of  oesophageal  disease.  It 
is,  of  course,  more  striking  in  cancer,  but  occurs  to  a  moderate  degree 
in  all  forms  of  stricture.  Fcetor  of  the  breath  attends  dilatation  of  the 
oesophagus. 

Emphysema  of  the  subcutaneous  connective  tissue  should  always  lead 
to  investigation  of  the  oesophagus.  Usually  it  is  found  to  have  been 
preceded  by  pronounced  symptoms  of  disease  of  the  oesophagus.  In 
rare  cases  ulceration  of  the  oesophagus  may  progress  without  symp- 
toms ;  its  course  extends  into  the  air-passages.  The  passage  of  air 
through  the  fistulous  communication  causes  subcutaneous  emphysema. 
It  is  of  frequent  occurrence  when  foreign  bodies  lodge  in  the -gullet. 

Physical  Examination.  Examination  of  the  oesophagus  is  made 
by  inspection  and  auscultation,  and  by  means  of  palpation  with  or 
without  a  bougie. 

Inspection  can  be  made  only  with  an  endoscope. 

Auscultation  of  the  oesophagus,  while  the  patient  is  swallowing  fluids, 
sometimes  confirms  the  results  obtained  by  instrumental  palpation  as 
to  the  seat  of  an  obstruction.  A  gurgling  sound  is  audible  as  the 
fluid  passes  the  obstruction. 

Palpation.  The  oesophagus  behind  the  trachea  in  the  neck  may  be 
palpated  when  it  is  enlarged,  as  in  abscess.  Palpation  yields  the  most 
positive  results. 

It  must  not  be  forgotten  that  the  normal  constriction  of  the  oesoph- 
agus is  situated  nearly  opposite  the  fouith  dorsal  vertebra,  ten  inches 
from  the  teeth.  The  bougie  is  used  to  determine  the  cause  of  the  diffi- 
culty in  swallowing.  If  the  cause  is  due  to  paralysis  or  to  spasm  of 
the  oesophagus,  the  bougie  can  usually  be  passed  with  ease.  If,  on  the 
other  hand,  it  is  due  to  organic  disease,  an  obstruction  will  be 'found. 
In  organic  disease  this  is  usually  in  the  upper  half  of  the  oesophagus. 
If  near  the  pharynx,  the  obstruction  is^  due  to  cicatricial  stricture.  If 
the  obstruction  is  encountered  nine  inches  from  the  teeth  or  about  the 
position  of  the  bronchus,  it  is  usually  due  to  cancer.  The  bougie 
should  not  under  any  circumstances  be  passed  if  there  are  grounds  for 
believing  there  is  an  aneurism.  Fatal  rupture  has  followed  its  passage 
under  such  circumstances. 

Method.  The  patient  should  be  seated  with  the  head  thrown  back 
sufficiently  far  to  make  the  passage  from  the  pharynx  to  the  oesophagus 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  OESOPHAGUS.     489 

almost  continuous.  The  operator  may  stand  behind  or  in  front  of  the 
patient.  The  bougie,  held  like  a  pen,  should  be  passed  through  the 
pharynx  and  guided  by  the  fingers  close  to  its  posterior  wall.  But  little 
force  should  be  used.  It  should  be  passed  slowly,  and  it  will  soon 
overcome  the  gagging.  The  bougie  should  be  warmed  and  oiled  before 
it  is  introduced.     The  handles  should  be  flexible,  the  bulb  olive-shaped. 

Obstruction  of  the  (Esophagus.  Dysphagia  is  a  symptom 
common  to  all  diseases  of  the  oesophagus.  It  may  vary  from  simple 
dysphagia  from  pain  in  all  degrees  up  to  complete  obstruction  of  the 
tube.  Dysphagia  from  obstruction  of  the  oesophagus  is  due  (1)  to 
disease  outside  of  the  canal,  (2)  to  disease  of  the  canal  itself,  and 
(3)  to  the  presence  of  a  foreign  body  in  the  canal.  In  the  considera- 
tion of  this  symptom,  therefore,  these  conditions  must  be  studied. 

1.  External  Pressure.  The  oesophagus  throughout  its  course  is  in 
intimate  relationship  with  the  trachea,  the  thyroid  gland,  the  carotid 
artery,  the  left  bronchus,  the  bronchial  glands,  the  arch  of  the  aorta,  and 
the  descending  aorta.  Disease  of  these  structures  which  admit  of  en- 
largement may,  therefore,  cause  difficulty  in  swallowing.  It  is  not 
likely  that  difficulty  of  deglutition  from  disease  of  the  trachea,  thyroid 
gland,  or  carotid  arteries  will  be  overlooked.  If  the  trachea  is  affected, 
dyspnoea  will  be  a  prominent  symptom;  if  the  thyroid  gland,  dyspnoea 
will  be  associated  with  dysphagia,  and  the  enlarged  gland  will  be  visible 
from  the  outside.  Disease  of  the  vertebras  is  not  likely  to  cause  obstruc- 
tion in  the  oesophagus,  for  it  would  not  press  that  organ  against  any 
other  solid  structure.  The  converse,  however,  is  true  :  disease  of  other 
structures  may  cause  difficulty  of  deglutition  by  pressing  the  oesophagus 
against  the  vertebra?.  Within  the  thorax,  disease  of  the  mediastinal 
glands,  aneurism  of  the  arch,  .or  the  descending  portion  of  the  aorta, 
an  enlarged  left  auricle,  a  pericardial  effusion  or  disease  of  the  left 
bronchus  might  cause  constriction  of  the  oesophagus.  The  medias- 
tinal glands  are  enlarged  from  tuberculosis,  carcinoma,  or  syphilitic 
disease.  The  occurrence  of  physical  signs  of  a  mediastinal  tumor, 
with  a  history  of  syphilis  or  the  general  symptoms  of  tuberculosis  or 
carcinoma,  would  point  to  the  presence  of  these  affections.  In  aneu- 
rism of  the  aorta,  in  its  arch  or  transverse  portion,  the  physical  signs 
and  subjective  symptoms  of  aneurism — with  accentuation  of  the  aortic 
second  sound  and  the  presence  of  atheroma — would  lend  color  to  the  view 
that  the  obstruction  is  of  this  nature.  In  both  instances  just  mentioned 
the  obstruction  rarely  goes  to  the  extent  of  preventing  the  passage  of 
li(|iiids.  In  enlargement  of  the  left  auricle  and  in  pericardial  effusion 
the  degree  of  difficulty  may  amount  simply  to  a  temporary  sense'  of 
obstruction  or  pain  about  the  point  where  food  passes  these  structures. 
If  the  early  physical  signs  arc  associated  with  an  enlarged  auricle,  with 
mitral  stenosis,  or  with  pericardial  effusion,  the  diagnosis  of  the  causal 
condition  is  easy.  It  is  particularly  important,  in  considering  difficulty 
of  deglutition  from  external  pressure,  to  remember  that  the  oesophagus 
is  in  close  relation  with  the  bronchus  on  the  left  side,  at  about  the 
fourth  dorsal  vertebra — this  is  ten  inches  from  the  teeth — in  case  it  is 
desirable  to  investigate  the  obstruction  with  a  probe.  Obstruction 
from  aneurism  of  the  descending  portion  of  the  arch  of  the  aorta  is 


490  SPECIAL  DIAGNOSIS. 

also  located  at  the  upper  portion  of  the  oesophagus,  nine  inches  from 
the  incisor  teeth. 

2.  Organic  Disease.  Difficulty  of  deglutition,  due  to  disease  of  the 
oesophagus  itself,  occurs  in  acute  inflammation,  in  chronic  inflammation, 
and  in  stricture,  which  is  always  the  result  of  traumatic  inflammation, 
syphilis,  or  cancer. 

Acute  inflammation  is  recognized  by  severe  pain  on  swallowing.  It 
is  associated  with  the  sensation  of  a  foreign  body  in  the  lower  portion 
of  the  throat.  There  may  be  tenderness  on  pressure  along  the  course 
of  the  pharynx.  The  pain  is  aggravated  by  speaking.  The  pain  may 
extend  along  the  vertebral  column  to  the  cardiac  end  of  the  stomach, 
and  is  usually  of  a  burning  or  raw  character.  "When  the  inflammation 
is  due  to  traumatism,  as  the  swallowing  of  acids  or  other  caustics,  the 
mouth  and  pharynx  show  the  effects  of  the  inflammation,  and,  in  addi- 
tion, there  is  agonizing,  burning  pain  at  the  root  of  the  neck  and  be- 
tween the  shoulders.  The  inflammation  is  usually  attended  by  erosion 
of  the  mucous  membrane,  and  hence  not  only  frothy  mucus  of  a  glairy 
character  is  expectorated,  but  also  blood  and  shreds  of  membrane. 
The  effect  of  the  corrosive  poisoning  on  the  general  system  is  marked. 
There  is  great  prostration.  Because  of  the  accompanying  gastritis 
there  is  intense  thiivt.  Acute  inflammation  of  the  oesophagus  may  end 
in  ulceration  or  iu  complete  cure.  The  traumatic  inflammation  is  fol- 
lowed by  chronic  inflammation,  which  ultimately  results  in  stricture. 

Chronic  inflammation  is  attended  by  pain  in  the  act  of  swallowing; 
viscid  mucus  is  expectorated,  usually  in  large  amounts.  Liquids  are 
swallowed  readily,  but  solids  with  great  difficulty. 

Abscess  of  the  (Esophagus.  The  acute  inflammation  may  terminate 
in  abscess.  The  abscess  usually  develops  slowly,  with  pain  on  swallow- 
ing and  increased  movements  of  the  neck.  When  the  abscess  is  high 
up  in  the  gullet  it  may  present  on  the  exterior  of  the  neck.  If  it  is 
situated  outside  of  the  oesophagus,  and  is  secondary  to  disease  of  the 
vertebrae,  it  is  slow  and  chronic  in  its  course;  fever  and  rigors  attend 
its  development. 

Stricture  of  the  (Esophagus  due  to  the  healing  of  ulcers,  following 
traumatic  inflammation,  is  recognized,  first,  by  the  gradual  development 
of  the  symptom,  by  the  painless  nature  of  the  obstruction  in  the  large 
majority  of  cases,  and  by  the  seat  of  the  obstruction.  It  is  readily 
found  if  the  tube  is  passed,  or  the  patient  can  localize  the  area  in  the 
upper  portion  of  the  oesophagus.  The  difficulty  of  deglutition  con- 
tinues over  such  a  long  period  of  time  that  the  nutrition  is  but  slowly 
interfered  with,  but  gradual  emaciation  with  coincident  anaemia  devel- 
ops eventually. 

Carcinoma  of  the  CEsophagus.  In  cancer  of  the  oesophagus  dyspha- 
gia is  the  most  prominent  symptom.  It  comes  on  gradually.  The 
patient  expectorates  a  considerable  quantity  of  frothy  mucus,  often  of 
blood,  and,  on  careful  examination,  caucerous  tissue  may  be  found. 
Pain  is  not  generally  very  severe.  Cough  is  usually  present,  due  to 
pressure  of  the  cancerous  mass  on  the  recurrent  laryngeal  or  pneumo- 
gastric  nerve.  Sometimes  the  cancer  appears  behind,  and  ulcerates 
into  the  trachea  or  bronchus.     When  this  complication  takes  place  the 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     491 

cough  is  violent.  Dyspnoea  from  pressure  is  likely  to  occur.  In  the 
course  of  cancer  perforation  of  the  oesophagus  into  the  air-passages 
may  take  place  and  cause  pulmonary  abscess  or  gangrene,  or  the  sudden 
appearance  of  dyspnoea,  and  shortly  the  onset  of  aspiration-pneumonia. 

The  difficulty  of  deglutition  due  to  cancer  must  be  distinguished  from 
that  of  traumatic  or  syphilitic  stricture  and  from  spasmodic  stricture 
and  paralysis  of  the  oesophagus.  The  history  of  the  case  aids  in  the 
recognition  of  traumatic  or  syphilitic  stricture,  while  the  ready  passage 
of  a  bougie  indicates  that  the  difficulty  is  spasm  or  paralysis.  Cancer 
usually  occurs  late  in  life  and  is  attended  with  rapid  emaciation.  Its 
complications,  more  common  than  in  other  obstructions,  are  attended 
with  fever  and  rapid  prostration.  Cancer  may  be  distinguished  from 
disease  outside  of  the  oesophagus  by  the  condition  of  the  stomach  beyond 
the  point  of  stricture.  If  there  is  cancer,  atrophy  is  more  likely  to 
take  place,  the  change  in  size  being  recognized  by  a  tube  or  by  inflat- 
ing the  stomach  with  air  or  fluids. 

"3.  Foreign  Body.  Stricture  or  difficulty  of  deglutition  from  the 
presence  of  foreign  bodies  is  usually  recognized  with  ease.  The  diffi- 
culty of  deglutition  is  due  to  the  foreign  body  and  to  the  spasm  excited 
by  the  mass.  In  consequence  of  the  latter  regurgitation  of  food  takes 
place.  In  the  first  place,  there  is  present  a  history  of  the  swallowing 
of  a  foreign  material.  Sudden  pain  succeeds  the  act,  while  there  are 
great  anxiety  and  distress,  particularly  if  the  body  is  a  large,  hard 
mass.  Xot  only  is  there  difficulty  in  deglutition,  but  also  dyspnoea. 
The  latter  is  due  to  pressure,  but  is  aggravated  by  the  nervous  state. 
When  the  foreign  body  is  small  the  dysphagia  is  moderate  in  degree 
and  the  reflex  irritation  slight,  although  nausea  and  vomiting  may  be 
common.  If  it  cannot  be  removed,  ulceration  and  abscess  take  place, 
the  further  course  of  which  depends  upon  the  seat  of  the  obstructing 
material.  Pain,  hemorrhage,  subcutaneous  emphysema,  and  the 
emission  of  air  are  symptoms  which  follow.  The  exact  location  of 
the  foreign  body  may  be  ascertained  by  the  use  of  the  Rontgen  rays, 
as  in  the  remarkable  case  of  White's. 

Harrison  Allen,1  in  his  exhaustive  essay,  calls  attention  to  several 
features.  Many  of  the  symptoms  are  primary  and  some  are  secondary. 
The  former  are  due  to  the  trauma  and  the  presence  of  the  foreign  body  ; 
the  latter  to  the  secondary  ulceration.  This  softening  and  ulceration  of 
the  walls  may  take  place  rapidly.  Allen  does  not  think  that  pain  or 
the  occurrence  of  convulsions  is  of  much  significance,  but  that  emphy- 
sema, the  excessive  secretion  of  mucus,  and  the  emission  of  air  are 
paramount.  Anxiety  he  considers  of  very  common  occurrence  and 
very  suggestive.  The  excessive  secretion  of  ropy  mucus,  salivation 
included,  is,  in  Allen's  judgment,  pathognomonic  of  disease  in  the 
pharyngo-larynx  or  in  the  oesophagus,  at  or  above  the  level  of  the  left 
bronchus.  This  secretion  may  be  an  early  indication  of  cancer  of  the 
oesophagus.  It  may  occur  in  aneurism.  When  ulceration  causes  a 
pulmonary  oesophageal  fistula  the  condition  may  simulate  thai  oJ 
phthisis. 

1  Foreign  Bodies  in  the  OEsophagus.    Allen  :  New  York  Medical  Journal,  August  17,  1895. 


492  SPECIAL  DIAGNOSIS. 

Dilatation  of  the  (Esophagus.  Primary  dilatation  of  the 
oesophagus  is  an  extremely  rare  affection.  The  chief  symptom  is  the 
regurgitation  of  food,  which  is  neutral  or  alkaline,  and  may  be  returned 
some  time  after  the  act  of  swallowing.  The  patient  sometimes  com- 
plains of  a  sensation  of  distention  along  the  course  of  the  oesophagus, 
with  heat  and  burning.  The  odor  of  the  breath  is  foetid.  If  the 
oesophagus  is  not  deflected,  a  bougie  can  be  passed  through  its  course. 

If  the  dilatation  is  secondary,  the  amount  of  dysphagia  depends 
upon  the  obstruction.  Food,  however,  is  not  returned  immediately. 
After  remaining  an  indefinite  time,  not  longer  than  two  hours,  it  is 
regurgitated  unchanged.  Bougies,  of  course,  do  not  pass.  In  saccu- 
lated dilatation,  which  usually  takes  place  in  the  posterior  wall  near 
the  pharynx,  a  bougie  may  sometimes  pass,  and  at  other  times  may  be 
caught  in  the  sac.  The  sac  may  be  enlarged  so  as  to  retain  a  consid- 
erable amount  of  food,  which  is  regurgitated  some  time  after  it  is 
swallowed.  A  sacculated  diverticulum,  from  traction  on  the  outside 
of  the  oesophagus,  may  occur  when  there  is  glandular  disease  of  the 
neck,  with  adhesions  to  the  oesophagus,  swelling  its  wall  outward. 

Functional  Affections  of  the  (Esophagus.  The  functional 
affections  are  quite  as  common  as  those  of  organic  disease  of  the  oesoph- 
agus. They  are  of  longer  duration,  but  are  unattended  by  the  same 
grave  effects  upon  the  general  system.  Spasm  is  one  of  the  most  fre- 
quent affections.  It  may  be  so  intense  as  to  lead  to  temporary 
stricture.  It  usually  occurs  in  women.  The  attack  comes  on  sud- 
denly during  the  act  of  swallowing  food.  The  food  is  at  once  regur- 
gitated. After  the  subsidence  of  the  perturbation,  swallowing  can 
be  accomplished,  if  it  is  done  slowly.  It  usually  occurs  in  hysteria. 
The  patient  may  have  had  some  slight  accident  in  the  performance 
of  the  ordinary  acts  of  deglutition,  out  of  which  grew  the  idea  that 
swallowing  cannot  be  accomplished.  In  consequence  the  further  acts 
are  performed  with  trepidation,  and  slight  emotional  disturbance  at 
the  table  may  cause  a  recurrence  of  the  sudden  spasm. 

Unfortunately  calling  attention  to  the  act  of  swallowing  always  has- 
the  effect  of  embarrassing  the  patient,  and  the  taking  of  a  meal  under 
unusual  circumstances  is  sure  to  be  attended  by  complete  dysphagia. 
Sometimes  the  idea  is  conceived  that  certain  forms  of  food  alone  cannot 
be  swallowed.  It  is  usually  solid  food  that  is  thought  to  give  the  dis- 
tress. Mitchell  says  that  the  dysphagia  occurs  early  in  cases  of 
hysteria  ;  unless  relieved,  the  hysterical  symptoms  are  likely  to  be 
transferred  to  the  stomach.  I  saw  a  female  patient  who,  after  an 
ordinary  choking  attack,  for  several  years  could  not  swallow  food  in 
the  presence  of  strangers,  or  after  the  slightest  emotional  disturbance, 
or  if  hurried.      The  spasm  disappeared  after  treatment  with  bougies. 

In  paralysis  difficulty  of  deglutition  is  the  main  symptom.  The 
course  of  oesophageal  paralysis  depends  upon  its  cause.  The  larynx  is 
usually  affected  at  the  same  time,  so  that  laryngeal  symptoms  are  pres- 
ent. Paralvsis  generally  comes  on  very  gradually.  It  may  be  due  to 
cerebral  hemorrhage,  tumor,  bulbar  paralysis,  or  to  general  paralysis 
of  the  insane.  The  bougie  passes  easily  and  does  not  cause  irritation. 
In  paralysis  there  is  no  regurgitation  of  food. 


CHAPTER  Y. 

DISEASES   OF  THE  STOMACH,   INTESTINES,  AND  PERITONEUM. 

In  the  succeeding  chapters  diseases  of  the  organs  within  the  abdomen 
will  be  discussed.  The  subjective  symptoms  that  attend  diseases  of 
the  various  organs  call  the  attention  of  the  observer  to  this  portion  of 
the  trunk — the  abdomen.  Examination  of  the  abdomen  is  made  with 
a.  view  to  ascertain  which  particular  organ  is  affected.  It  is  proper, 
therefore,  before  a  consideration  of  the  diseases  of  each  organ,  to  dis- 
cuss the  examination  of  the  abdomen  as  a  whole  and  the  subjective 
symptoms  referable  to  this  region.  It  will  be  profitable  to  consider 
the  topographical  anatomy  of  the  abdominal  organs  when  the  diseases 
of  each  are  considered. 

Fig.  99. 


The  quadrants  of  the  abdomen. 

The  abdomen  is  divided  into  various  regions  by  vertical  and  trans- 
verse lines,  to  enable  us  to  locate  the  various  organs  and  their  dis< 
Unfortunately,  the  regions  do  not  afford  limitations  for  organs  in 
health.  Simplicity  should  hold  in  these  arbitrary  matters,  and,  more- 
over, a  method  of  delimitation  that  is'  commonly  used  in  the  subdi- 
vision of  other  regions  should  be  adopted,  for  the  sake  of  uniformity 
of  description  and  to  assist  the  memory  of  the  learner.     For  these 


494  SPECIAL  DIAGNOSIS. 

reasons  Ballance's  method  of  dividing  the  surface  is  the  best.  This 
author  includes  the  abdomen  within  a  circle  which  has  the  umbilicus  as 
its  centre.  The  circle  is  divided  into  quadrants  by  diameters  drawn  at 
right-angles,  corresponding  to  the  median  and  transverse  umbilical 
lines.  The  portions  to  the  right  of  the  middle  lines  are  the  right 
upper  and  lower  quadrants  respectively  ;  the  portion  to  the  left,  the 
left  upper  and  lower  quadrants. 

With  the  abdomen  thus  divided,  the  umbilicus  and  fixed  bony  struc- 
tures in  the  periphery  of  the  circle  serve  as  points  from  which  meas- 
urements are  made  to  indicate  the  exact  position  of  the  structure. 
The  circle  may  be  further  divided  by  other  radii.  To  locate  a  tumor 
in  the  right  lower  quadrant,  for  instance,  the  umbilicus,  pubic  bone, 
and  anterior  spine  of  the  ilium  may  be  used  as  points  from  which  to 
measure  the  distance.  Measurements  may  also  be  made  along  the 
radii  extending  from  the  umbilicus  to  fixed  points.  The  following  is 
a  useful  method  :  A  tumor  is  situated  in  the  right  lower  quadrant ; 
the  centre  of  the  tumor  is  two  inches  below  a  point  on  the  transverse 
umbilical  line,  three  inches  from  the  centre  ;  it  is  also  three  inches  to 
the  right  of  a  point  on  the  median  line,  two  inches  from  the  umbilicus. 
The  size  of  the  tumor  can  be  defined  by  measurements  from  its  own 
centre.  Organs  bisected  by  the  median  line,  as  the  bladder  and  uterus, 
can  be  described  as  situated  in  the  median  line,  so  many  inches  to  the 
right  and  left,  as  the  case  may  be,  and  the  distance  in  inches  from 
the  pubis. 

The  right  upper  quadrant  includes  the  right  lobe  of  the  liver,  the 
gall-bladder,  pylorus,  transverse  colon.,  a  portion  of  the  pancreas,  the 
pyloric  orifice  near  the  median  line,  and,  deeper,  the  upper  half  of  the 
kidney  ;  the  left  upper  quadrant,  the  left  lobe  of  the  liver,  the  stom- 
ach, the  pancreas,  the  upper  portion  of  the  kidney  and  the  spleen  ; 
the  right  lower  quadrant,  the  csecum,  appendix  vermiformis,  right 
tube  and  ovary,  a  portion  of  the  bladder  and  uterus,  and,  above,  the 
lower  part  of  the  kidney  at  the  end  of  full  inspiration  ;  the  left  lower 
quadrant,  the  corresponding  tube,  ovary,  and  portions  of  the  bladder 
and  uterus,  and  the  sigmoid  flexure  of  the  colon;  but  not  likely  the 
lower  part  of  the  kidney,  as  it  is  one-half  inch  or  more  higher  than  the 
right  (Holden).  About  the  centre  and  extending  to  the  periphery  on 
all  sides  are  the  small  and  lar^e  intestines. 


The  Data  Obtained  by  Inquiry.      The  Subjective  Symptoms 
of  Abdominal  Disease. 

This  class  of  symptoms  will  be  discussed  in  the  articles  devoted  to 
affections  of  the  particular  organs  of  the.  abdomen,  because  the  symp- 
toms are  usually  directly  referred  by  the  patient  to  the  affected  organs. 
They  are  local  sensations  of  heat,  fulness,  or  distention,  of  burning, 
of  weight,  or  of  undue  motion.  Local  sensations  of  weight,  fulness, 
or  distention  are  due  to  enlargements  or  to  displacements  of  organs 
(liver,  kidneys),  or  to  tumors.  Heat  or  burning  is  described  in  inflam- 
matory tumors,  as  pyosalpinx.  It  is  often  difficult  for  the  sufferer  to 
define  the  location  of  pain  in  the  abdomen  and  describe  its  features. 


DISEASES  OF  STOMACH,  INTESTINES, 'AND  PERITONEUM.     495 

Moreover,  the  pain  is  frequently  due  to  disease  of  the  walls  of  the 
abdomen,  which  may  increase  the  confusion.  Pain  must  be  investi- 
gated by  an  examination  of  each  structure  in  close  proximity  to  the 
part  complained  of  as  painful.  The  state  of  the  function  of  each 
organ  must  also  be  inquired  iuto. 

Pain  due  to  Disease  of  the  Structures  of  the  Abdominal  Walls.  The 
skin,  the  nerves,  the  muscles  and  fascia,  the  connective  tissue,  may  be 
the  seat  of  pain.  If  the  skin  is  affected,  the  pain  is  usually  localized 
and  of  moderate  degree  of  severity.  There  is  superficial  tenderness. 
There  are  evidences  of  inflammation,  as  erythema  or  ulcers.  Pain  due 
to  affections  of  the  nerves  is  seen  in  simple  neuralgia  and  herpes  zoster. 
Herpes  zoster  is  recognized  by  the  localized  neuralgic  character  of  the 
pain  in  the  distribution  of  superficial  nerves  and  the  peculiar  eruption 
which  follows.  Neuralgias  are  recognized  by  the  well-known  points 
of  tenderness,  the  intermittent  character  of  the  pain,  and  the  associa- 
tion with  anaemia  ;  neuritis  may  be  present,  with  the  usual  objective 
signs.  A  common  cause  of  pain  in  the  abdomen  is  disease  of  the 
vertebra?  with  pressure  upon  the  peripheral  nerves  at  their  emergence 
from  the  spinal  column.  The  pain  is  situated  in  the  median  line, 
either  below  the  ensiform  cartilage  or  around  the  navel  ;  it  is  an  inter- 
mittent pain.  Aneurism  of  the  abdominal  aorta,  with  pressure  upon 
and  erosion  of  the  vertebra?,  causes  the  same  kind  of  pain.  The  mus- 
cles and  fascia  may  be  the  seat  of  rheumatism,  causing  severe  pain. 
The  muscles  may  be  tender.  Movement  always  increases  the  pain, 
and  sighing,  laughing,  or  coughing  may  aggravate  it.  The  pain  may 
be  so  diffuse  and  severe  as  to  cause  it  to  be  confounded  with  periton- 
itis. The  presence  of  rheumatism  in  other  muscles,  of  moderate  fever 
without  gastro  intestinal  disturbance,  of  uric  acid  and  urates  in  excess, 
due  to  the  rheumatic  diathesis,  point  to  the  true  condition. 

The  seat  of  the  pain  will  be  considered  in  discussing  the  special 
organs  and  their  diseases.  In  general  it  may  be  said  that  the  seat  of 
the  pain  is  a  fair  index  of  disease  of  some  structure  in  the  part  indicated. 
AVhen  the  pain  is  general  it  points  to  rheumatism  or  to  peritonitis. 

Character  of  Pain.  Pain  in  the  abdomen  may  be  acute  or  may  con- 
tinue over  a  long  period  of  time.  Acute  pain  points  to  inflammation, 
to  perforation,  to  gastralgia,  to  enteralgia,  or  to  occlusion  of  channels, 
of  which  the  abdomen  contains  so  many  ;  chronic  pain,  to  ulcer,  to 
chronic  processes,  or  to  gastric  or  intestinal  neurosis. 

Mode  of  Onset.  Attacks  of  severe  pain  may  be  sudden  in  onset, 
or  the  culmination  of  slight  sensations  of  discomfort  progressively 
increasing  in  severity.  Attacks  of  sudden  pain  arc  spoken  of  as  colic  ; 
the  onset  is  sudden  ;  the  pain  is  paroxysmal  ;  each  spasm  of  pain  may 
be  attended  by  vomiting,  rapid  pulse,  cold  extremities,  cold  sweat,  and 
more  or  less  collapse,  except  in  lead-colic.  Such  pain  is  seen  in  intes- 
tinal colic,  hepatic  colic,  renal  colic,  and  in  uterine  and  vesical  colic. 

Sudden  pain  occurs  in  perforation  of  some  one  of  the  hollow  viscera, 
indicated  by  the  history  and  location  of  the  disease  of  the  part  affected 
and  the  character  of  the  symptoms  attending  the  pain.  Thus,  in  cases 
of  gastric  ulcer,  the  symptoms  of  which  may  be  known,  sudden  pain, 
indicating  perforation,  may  take  place  in  the  course  of  the  disease. 


496 


SPECIAL  DIAGNOSIS. 


The  Data  Obtained  by  Observation.     The  Objective  Symptoms, 

It  must  be  remembered  that  objective  symptoms  of  abdominal  change 
are  not  alone  due  to  disease  of  the  abdominal  contents,  but  also  to 
disease  elsewhere.  Thus  the  abdomen  may  be  enlarged  from  the 
ascites  of  cardiac  or  renal  disease,  contracted  in  tuberculous  meningitis. 

Disease  or  paralysis  of  the  diaphragm  alters  the  appearance  of  the 
upper  half  of  the  abdomen  and  its  movements  in  respiration.  Fluc- 
tuating changes  in  size  occur  in  hysteria  and  gastric  neurasthenia,  and 
permanent  change  in  tuberculous  meningitis. 

Inspection.  In  general  inspection  of  the  abdomen,  attention  should 
be  directed,  first,  to  the  size  and  shape  ;  second,  to  the  color  and  to  the 
presence  of  normal  or  abnormal  markings ;  third,  to  pulsations  and 
unusual  movements  of  some  of  the  viscera  ;  fourth,  to  the  condition 
of  the  abdominal  walls,  and,  fifth,  to  the  appearance  of  the  veins. 

Increase  in  size  may  be  general  or  local. 

General  Enlargement  of  the  Abdomen.  The  abdomen  dif- 
fers very  much  in  size  in  different  persons,  depending  not  only  upon  the 
thickness  of  the  fat  in  the  abdominal  walls  and  omentum,  but  upon 
the  calibre  of  the  intestines  themselves,  which  are  apt  to  be  much 


The  shading  indicates  the  position  of  the  percussion-dulness  in  a  case  of  ascites,  while  the 
patient  is  lying  on  the  back,  the  fluid  falling  to  the  low  levels  in  the  flanks,  and  the  umbilical 
region  remaining  clear.    (Finlayson.) 

distended  in  those  accustomed  to  eat  large  meals.  In  general,  the 
belly  is  more  protuberant  in  infants  and  children  than  in  adults.  En- 
largement occurs  in  obesity,  and  it  is  often  difficult  to  tell  whether  the 
excessive  deposit  of  fat  in  the  abdominal  walls  and  omentum  accounts 
for  the  whole  enlargement  or  only  serves  to  mask  the  presence  of  a 
tumor.  Enlargement  of  the  belly  is"  only  a  part,  though  frequently 
the  most  pronounced  evidence  of  obesity;  whereas,  in  enlargements  of 
the  abdomen  from  tumors  and  ascites,  there  is  usually  a  marked  con- 
trast between  the  size  of  the  abdomen  and  that  of  the  rest  of  the  body. 
In  enlargement  from  ascites,  when  the  patient  is  lying  upon  his  back 
the  front  of  the  abdomen  is  flattened,  while  the  flanks  bulge.  If  he 
turns  upon  his  side,  the  flank  which  is  uppermost  becomes  hollowed 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     497 

out  and  the  front  of  the  belly  is  prominent.  This  is  the  appearance 
in  moderately  large  effusions  which  have  existed  long  enough  to  stretch 
the  lateral  abdominal  muscles.  When  the  effusion  is  enormous  all 
parts  of  the  belly  are  distended,  and  the  abdomen  is  barrel  shaped ;  no 
change  of  shape  occurs  upon  change  of  posture.     (Fig.  100.) 

Enlargement  from  accumulation  of  gas  within  the  bowels  is  general, 
and  may  attain  a  very  high  degree,  giving  the  abdomen  a  uniform 
arched  appearance  resembling  a  barrel.  The  diaphragm  may  be 
pressed  upward  so  far  as  to  interfere  seriously  with  respiration  and 
heart-action.  In  debilitated  children  the  enlargement  due  to  flatulency 
is  associated  with  flaccid  abdominal  Avails,  causing  lateral  and  central 
enlargement.  Moderate  degrees  of  distention  from  gas  in  the  intestines 
may  be  the  result  of  eating  certain  articles  of  food,  such  as  turnips  or 
beans.  Excessive  accumulations  are  met  with  in  typhoid  fever  ;  peri- 
tonitis, operative  and  non-operative  ;  and  in  stenosis  of  the  colon  or 
rectum  from  any  cause.      They  are  also  common  in  hysteria. 

In  the  last  month  or  two  of  pregnancy  enlargement  of  the  abdomen 
is  general,  especially  in  a  woman  who  has  previously  borne  children. 

General  enlargement  of  the  abdomen  may  be  due  also  to  cancer  of 
the  peritoneum,  to  hydatid  cyst,  and  to  cancer  of  the  bowel.  It  has 
been  observed  in  children  in  dilatation  of  the  colon.  The  abdomen 
was  uniformly  enlarged  in  Hughes'  case  and  in  Osier's  cases.  Coils 
of  the  intestine,  with  waves  of  peristalsis,  were  seen  through  the  thin 
abdomiual  walls.  Formad's  case  occurred  in  an  adult.  The  disten- 
tion was  enormous.     Constipation  attended  all  these  cases. 

Fir.  101. 


Ascites.    Upper  limits  of  dulness  indicated  by  the  dotted  line.    Umbilicus  prominent. 

Other  causes  of  abdominal  enlargement  are  diseases  of  the  liver  and 
gaU-bladder.  When  these  are  enlarged  a  local  swelling  may  be  de- 
tected in  the  right  upper  quadrant  ;  but  when  they  attain  very  large 
dimensions,  as  happens  not  infrequently,  in  cancer,  amyloid  disease, 
and  hydatid  liver,  inspection  may  be  able  to  detect  only  general  en- 
largement, witli  small  prominences  corresponding  with  cancerous  nod- 
ules or  small  cysts. 

Splenic  enlargements,  which  attain  the  greatest  size,  are  from  leuk- 
aemia or  chronic  malarial  poisoning,  and  are  usually  visible  only  as 
general  enlargements  of  the  belly.     There  may,  however,  be  greater 

32 


498  SPECIAL  DIAGNOSIS. 

prominence  over  the  lower  left  ribs  and  in  the  left  upper  quadrant 
posteriorly. 

In  diseases  of  the  kidney  producing  great  enlargement  there  is  usually 
visible  a  prominence  in  the  lateral  and  lumbar  region  of  the  side  cor- 
responding with  the  kidney  involved,  unless  there  is  considerable  ema- 
ciation ;  anteriorly  the  enlargement,  if  any  be  visible,  usually  appears 
to  be  general. 

Enlargements  of  the  abdomen  which  begin  in  the  lower  quadrants 
are  usually  of  pelvic  origin.  The  most  common  are  those  due  to 
pregnancy,  cysts  of  the  ovary  or  parovarium,  fibroids  and  fibre- cysts 
of  the  uterus,  and  abscesses  or  effusions  (chronic  peritonitis).  A 
greatly  distended  bladder  may  cause  confusion  ;  it  is  a  good  rule  to  be 
sure  that  the  bladder  is  empty,  by  having  a  catheter  passed  before 
proceeding  further  with  the  examination.  Intestinal  peristalsis  is 
observed  in  constriction  of  the  bowels.  The  motion  of  the  intestine 
above  the  seat  of  stricture  is  wave-like  or  worm-like,  and  the  bowel 
itself  dilated. 

Local  Enlargement  or  Tumors  of  the  Abdomen.  In  the 
space  below  the  xiphoid  cartilage  and  between  the  ribs  (epigastrium) 
local  enlargements  may  be  due  to  a  distended  or  dilated  stomach  or  to 
a  tumor  of  the  pylorus,  Avhich  is  almost  always  cancerous.  Promi- 
nence in  this  region  is  seen  in  large  eaters.  But  enlargement  in  this 
region  is  sometimes  due  to  cysts,  sclerosis  or  cancer  of  the  pancreas,  to 
aneurisms,  to  cancer  of  the  large  intestine  or  tumor  of  the  left  lobe  of  the 
liver.  It  is  in  this  region  or  to  the  left  of  the  median  line  and  nearer 
the  umbilicus  that  the  effusions  into  the  lesser  peritoneal  cavity  are 
found. 

A  rigid  rectus  muscle  is  capable  of  simulating  a  tumor.  Likewise, 
in  hysterical  subjects,  rigid  abdominal  muscles,  with  tympanites,  give 
rise  to  a  swelling  known  as  ee phantom  tumor."  Such  swelliugs  are  less 
constaut  in  shape  and  character  than  geuuine  tumors,  and  although  dull 
on  percussion  appear  more  superficial;  they  sometimes  disappear  under 
friction  with  the  hand,  and  certainly  under  full  anaesthesia ;  the  stig- 
mata of  hysteria  are  present. 

Enlargements  in  the  right  upper  quadrant  (right  hypochondrium) 
are  most  frequently  due  to  diseases  of  the  liver  [q.  v.)  and  to  affections 
of  the  gall-bladder.  Less  frequently,  a  much  enlarged  kidney  or  a 
hydronephrosis  causes  swelling  in  this  region.  The  differential  diag- 
nosis is  made  by  the  history  of  the  case  and  by  noting  the  direction  in 
which  the  tumor  has  grown,  by  examination  of  the  urine,  and  by  the 
relation  which  the  ascending  colon  bears  to  the  tumor  ;  kidney  tumors 
carry  it  in  front  of  them  as  they  grow;  hence  their  duluess  is  obscured 
by  the  superficial  tympany  of  the  colon. 

Enlargement  in  the  right  lower  quadrant  (right  iliac  region)  is  most 
frequently  due  to  affections  of  the  caecum  and  appendix,  to  tumors  of 
the  ovary,  and  to  pelvic  abscesses. 

The  diseases  of  the  caecum  and  appendix  causing  enlargement  in  the 
right  iliac  fossa  are  faecal  accumulation,  typhlitis,  faecal  abscess,  peri- 
typhlitic  abscess,  carcinoma,  and  stricture  of  the  ileo-caecal  valve. 

The  diseases  of  the  ovaries  and  tubes  causing  enlargement  in  this 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     499 

region  are  ovarian  tumors,  cysts  of  the  broad  ligament,  pelvic  abscess 
(usually  tubal  in  origin),  and  extrauterine  pregnancy. 

Other  affections  which  need  to  be  considered  are  tubercular  peri- 
tonitis, acute  and  chronic,  and  enlarged  or  movable  kidney. 

Enlargement  in  the  left  upper  quadrant  (left  hypochondriac  region) 
is  due  to  dilatation  or  carcinoma  of  the  stomach  ;  enlargement  of  the 
spleen,  movable  kidney,  or  tumors  of  the  kidneys,  and  effusion  in  the 
lesser  peritoneal  cavity.  Enlargement  in  the  left  loiver  quadrant  (left 
iliac  region)  is  due  to  tumors  (cancerous)  of  the  sigmoid  flexure  and 
to  the  tumor  due  to  volvulus,  and  to  the  same  causes  of  enlargement  of 
the  right  side  which  are  possible  on  the  left. 

Enlargement  about  the  centre  of  the  abdomen  (umbilical  region)  may 
be  due  to  umbilical  hernia,  to  a  floating  kidney,  spleen,  or  liver,  or  to 
tubercular  disease  of  the  omentum  or  mesenteric  glands.  It  is  seen  in 
cases  of  dilatation  after  a  full  meal.  This  region  is  frequently  enlarged, 
in  conjunction  with  a  more  prominent  swelling  extending  from  the 
sternum,  in  cancer  of  the  stomach;  and  from  the  ribs  on  the  right  in 
cancer  of  the  liver  or  gall-bladder,  or  other  diseases  of  these  viscera; 
from  the  ribs  on  the  left,  in  effusions  into  the  lesser  peritoneal  cavity, 
disease  of  the  pancreas  or  the  spleen.  Undue  projection  of  the  verte- 
bra? must  not  be  mistaken  for  tumors. 

Enlargement  above  the  pubis  (hypogastric  region)  is  due  most  fre- 
quently to  enlargement  of  the  uterus  from  pregnancy,  fibroid  tumors, 
or  fibro-cysts,  or  to  distention  of  the  bladder;  but  is  also  common  in 
gastric  dilatation  and  gastroptosis ;  flattening  of  the  upper  half  is  then 
seen,  and  the  lesser  curvature  is  then  made  out. 

Enlargement  in  the  lateral  regions  and,  behind  (lumbar  region)  may 
occur  in  malignant  tumors  of  the  kidney,  in  hydro-  and  pyonephrosis, 
in  periuephritic  abscess,  and  in  renal  cysts  of  large  size.  Usually  renal 
enlargements  of  any  kind  are  not  observed  lehind  however.  It  may 
also,  in  the  left  side,  be  due  to  perigastric  sub- diaphragmatic  abscess, 
and  to  enlargement  and  displacement  of  the  spleen.  On  the  right  side 
the  cause  may  be  enlargement  of  the  liver  or  a  hydatid  cyst. 

Diminution  in  Size.  The  abdomen  is  diminished  in  size  in  wast- 
ing diseases,  or  such  as  result  in  insufficient  food  being  taken.  This 
class  comprises  cancer  of  the  oesophagus  and  stomach,  chronic  lead- 
poisoning,  anorexia  nervosa,  and  chronic  diarrhoea  and  tuberculosis  of 
childhood.  In  the  second  stage  of  tubercular  meningitis  in  children 
there  is  retraction  of  the  abdomen.  The  wasting  of  the  subcutaneous 
and  the  omental  fat  and  atrophy  of  the  abdominal  organs  cause  the 
abdomen  to  be  concave  or  scaphoid. 

The  Shape.  In  general  enlargement  the  shape  is  uniform.  In 
large  accumulations  of  fat,  in  women  with  relaxed  abdominal  walls, 
the  abdomen  may  be  pendulous.  In  ascites  the  tissue  over  the  umbil- 
icus may  protrude,  changing  the  uniform  appearance.  Abdominal 
enlargements  due  to  ascites,  in  women  whose  abdominal  Avails  have 
previously  been  relaxed,  sometimes  assume -a  peculiar  cone-shape  ;  the 
base  corresponding  to  the  plane  of  the  abdomen,  the  apex  rising  below 
the  umbilicus.  This  is  particularly  the  case  if  the  patient  has  had  to 
assume  the  semi-erect    position  for  some  time.      It  is  often  difficult  to 


500  SPECIAL  DIAGNOSIS. 

decide  when  to  tap  in  such  cases.  In  local  enlargements  the  surface 
is  often  irregular,  corresponding  to  the  seat  of  the  enlargement.  The 
shape  changes  in  hysterical  distention.  In  enlargement  due  to  wast- 
ing disease  of  the  viscera,  as  cancer  of  the  retro-peritoneal  glands,  the 
abdomen  retracts  in  the  later  stage  of  the  disease,  causing  undue  prom- 
inence of  the  viscera  affected  by  carcinoma. 

The  Color.  The  abdomen,  in  general,  partakes  of  the  hue  of  the 
skin.  It  is  darker  around  the  umbilicus.  In  Addison' s  disease  a  dis- 
tinct areola  often  forms.  The  median  line,  from  the  umbilicus  to  the 
pubis,  darkens  in  pregnancy — the  "  brown  line."  It  is  sometimes  seen 
in  men.  The  skin  of  the  abdomen  is  the  seat  of  specific  eruptions,  as 
in  typhoid  fever,  and.  of  sudamina.  The  walls  may  be  pale  and  glis- 
tening in  oedema. 

Markings.  In  first  pregnancies  and  great  ascites,  less  frequently  in 
obesity  and  tumors,  striae  are  produced  in  the  parts  of  the  skin  where 
the  tension  has  been  greatest.  In  pregnancy  they  form  sinuous  lines 
upon  the  lower  lateral  portions  of  the  abdominal  wall  and  upon  the 
upper  inner  portions  of  the  thighs.  When  first  developed  they  are 
reddish,  but  subsequently  become,  by  a  process  of  fading,  more  glis- 
tening and  white  than  the  rest  of  the  skin.  They  are  also  known  as 
"  water  lines,"  and  linece  albicantes. 

The  Movements  (see  the  Lungs — Dyspnoea).  The  upper  zone 
participates  in  respiratory  movements,  especially  in  males.  In  enlarge- 
ment of  the  abdomen  and  in  upper  abdominal  tumors  the  movement 
is  restricted.  In  paralysis  of  the  diaphragm  the  normal  respiratory 
swelling  is  reversed;  the  tissues  at  the  costal  margin  sink  in.  Abdo- 
minal pulsations  are  observed.  The  region  below  the  sternum  (epigas- 
trium) is  a  common  seat,  but  pulsation  may  occur  anywhere  in  the 
course  of  the  aorta  (see  Epigastric  Pulsation). 

Peristaltic  movement  may  be  seen  through  the  abdominal  walls,  either 
of  the  stomach,  the  large  or  the  small  intestine.  If  of  the  large  intes 
tine,  the  waves  are  confined  to  the  seat  of  this  canal ;  if  in  the  small 
intestine,  to  the  region  around  the  umbilicus.  It  is  due  to  obstruction 
of  thepylome  or  of  the  lumen  of  the  bowels.  Pulsation  of  the  liver 
may  be  observed  (see  Dilatation  of  Heart). 

The  Veins.  Enlargement  of  the  superficial  veins  is  a  common 
accompaniment  of  cirrhosis  of  the  liver  and  stasis  of  the  portal  circu- 
lation, as  well  as  of  any  cause  Avhich  obstructs  the  free  circulation  in 
the  inferior  vena  cava.  Occasionally  a  varicose  condition  of  the 
veins  about  the  umbilicus  is  seen  {caput  Medusae). 

General  Palpation  and  Percussion  of  the  Abdomen.  Palpa- 
tion and  percussion  in  diseases  of  the  abdomen  may  be  discussed  to- 
gether. Generally  the  best  position  is  the  recumbent  one,  because  it 
admits  of  examination  without  too  great  exposure,  and  because  in  that 
position  the  abdominal  muscles  are  partly  relaxed.  When  the  muscles 
need  to  be  still  further  relaxed  the  patient  should  lie  upon  the  back, 
with  the  head  and  thorax  partly  elevated  and  the  knees  drawn  up. 
The  examining  hand  should  be  warm,  as  the  application  of  a  cold 
hand  throws  the  abdominal  muscles  iuto  involuntary  contraction.      In 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     501 

certain  obscure  tumors  much  can  be  learned  by  having  the  patient  rest 
on  the  hands  and  knees,  or  assume  a  knee-chest  position.  A  good 
plan  to  secure  relaxation  for  palpation  of  the  liver  and  spleen  is  to 
have  the  patient  sit  on  a  chair  with  body  leaning  forward  ;  then  flex 
the  thighs,  supporting  the  flexed  leg  on  a  stool  or  the  rung  of  a  chair. 
By  this  means  we  can  determine  if  the  pulsation  is  due  to  aneurism 
or  to  a  tumor.  The  latter  falls  away  from  the  vessels,  and  hence 
pulsation  is  lessened  thereby  in  the  knee-chest  position.  A  tumor  sur- 
rounded by  coils  of  intestine  may  thus  become  more  palpable. 

Moreover,  by  grasping  the  abdominal  walls  between  the  thumb  and 
fingers  their  thickness  and  the  relative  proportion  of  fat  can  be  esti- 
mated. So,  too,  the  presence  or  absence  of  oedema  of  the  skin  can  be 
readily  detected.  This  oedema  is  general,  but  is  especially  marked  in 
the  lateral  and  posterior  portions  of  the  abdomen.  Relaxed  abdominal 
walls  occur  after  dropsy  and  pregnancy.  Redundant  skin  remains  in 
folds  when  pinched  up.     This  is  particularly  so  in  abdominal  cancer. 

When  it  is  desired  to  explore  deeply  the  patient  should  be  instructed 
to  breathe  with  the  mouth  open,  and  the  examining  hand  pressed  firmly 
in  during  respiration,  and  held  there,  if  need  be,  during  several  long 
respirations.  The  palm  of  the  hand  should  be  laid  upon  the  surface ; 
after  the  muscles  are  relaxed  the  fingers  may  be  used  to  palpate  after 
flexion.  The  same  procedure  is  adopted  when  we  desire  to  get  the 
percussion -note  of  a  body  lying  deep  in  the  abdomen  :  the  finger 
is  pressed  firmly  and  deeply  in,  and  then  percussed.  In  this  way  any 
superficial  resonance  due  to  overlying   intestine  is  largely  eliminated. 

AYhen  palpating  to  determine  the  lower  edge  of  the  liver  or  spleen 
the  palmar  surface  of  the  fingers  is  pressed  into  the  abdomen  at  differ- 
ent levels  from  below. upward  until  the  edge  is  felt.  The  edge  of  the 
right  lobe  of  the  liver  in  its  normal  position  extends  to  the  margin  of 
the  ribs.  It  may  be  detected  by  pressing  the  fingers  in  as  described 
and  having  the  patient  take  a  long  breath. 

By  palpation  the  information  obtained  by  inspection  is  confirmed  ; 
the  character  of  the  abdominal  walls  and  of  swellings  is  determined; 
the  precise  location  of  pain  is  ascertained  ;  the  condition  at  the  her- 
nial rings  and  the  movability  of  tumors  are  investigated.  The  con- 
dition of  the  integument  should  first  be  determined.  Passing  the  hand 
gently  over  it  is  sufficient  to  decide  whether  it  is  normal,  smooth  anel 
elastic,  or  harsh  and  dry.  Any  markeel  unevenness,  such  as  is  produced 
by  umbilical  and  inguinal  hernia,  by  stripe,  or  by  large  tumors  of  the 
pylorus,  or  cancerous  nodules,  and  hydatid  cysts  of  the  liver,  can 
readily  be  detected.  The  degree  of  tension  of  the  abdominal  walls  is 
easily  appreciated.  It  is  increased,  of  course,  in  all  forms  of  great 
enlargement,  but  not  equally;  some  persons  are  so  sensitive  to  touch 
that  any  attempt' at  palpation  throws  the  abdominal  muscles  into  such 
rigid  contraction  that  examination  is  impossible.  Rigidity  of  the 
abdominal  walls  may  be  the  only  sign  of  acute  peritonitis.  It  \>  com- 
mon in  local  peritonitis.  The  recti  muscles  contract  quickly  on  hur- 
ried palpation.  Local  contractions  point  to  inflammation  underneath. 
In  tuberculous  peritonitis  we  see  distention  with  board-like  rigidity 
or  preternatural  hardness.     The  term  carreau   is  used  by  the  French 


502  SPECIAL  DIAGNOSIS. 

for  this  condition.  Peritoneal  friction  maybe  detected  most  frequently 
over  the  liver  and  in  chronic  peritonitis. 

Palpation  and  Percussion  of  the  Lower  Quadrants.  On 
the  right  side,  the  groups  of  affections  connected  with  the  caecum  and 
appendix,  the  uterine  appendages,  and  the  peritoneum,  which  cause 
enlargement  in  this  region,  have  been  mentioned  already  under  local 
inspection  of  the  abdomen.  Palpation  and  percussion,  however,  are 
the  methods  which  afford  the  most  exact  information  of  their  physical 
characteristics  and,  with  the  clinical  history,  enable  us  to  distinguish 
one  from  the  other. 

Diseases  of  the  Appendix  and  Cceeum.  The  information  supplied 
by  palpation  and  percussion  in  perforation  of  the  appendix  will  depend 
upon  the  rapidity  with  which  perforation  has  supervened  and  upon  the 
stage  at  which  the  examination  is  made. 

Generally  speaking,  after  the  sudden  onset  of  pain  in  the  right  iliac 
fossa,  in  a  person  previously  in  good  health,  there  is  tenderness  on  pal- 
pation in  that  region.  This  tenderness  is  first  localized,  but  may 
spread  with  great  rapidity  over  the  whole  abdomen.  Or  the  tender- 
ness may  at  first  be  general,  and  subsequently  become  localized  over 
the  appendix.  Subsequently,  the  tension  in  the  part  is  increased,  the 
overlying  abdominal  muscles  are  rigid  (spasm)  and  firm,  and  the  -per- 
cussion-resonance impaired.  Examination  with  the  finger  in  the  rectum 
may  discover  a  tense,  swollen  appendix,  or  a  tumor  in  the  pelvis. 

But  the  disease  may  be  fulminating  in  character,  perforation  being 
followed  by  the  rapid  development  of  peritonitis,  with  collapse,  so  that 
when  the  patient  is  seen  there  will  be  no  more  tenderness  over  one  part 
of  the  abdomen  than  over  another. 

Again,  the  appendix  may  be  subject  to  repeated  attacks  of  inflam- 
mation without  perforation,  but  with  the  development  of  local  peri- 
tonitis. There  is  increased  thickening  in  the  region  of  the  caecum, 
tenderness,  diminished  resonance,  and  increased  resistance  to  the  per- 
cussed finger.  Sometimes  an  enlarged  and  hardened  appendix  can  be 
made  out  by  palpation,  both  during  an  attack  and  in  the  intervals. 

In  still  other  cases,  of  slower  development,  a  distinct  perityphlitis 
abscess  develops.  In  addition  to  local  pain  and  tenderness  a  swelling 
appears  above  Poupart's  ligament.  The  skin  over  it  becomes  brawny 
and  pits  on  pressure  with  the  finger-tips.  The  tumor  is  dull  on  per- 
cussion, and  on  palpation  obscure  deep-seated  fluctuation  may  be  secured. 
A  fluctuating  tumor  may  also  be  made  out  by  rectal  examination  with 
the  finger. 

In  fcecal  impaction  of  the  cceeum  a  tumor  forms,  following  the  course 
of  the  caecum,  and  directed  upward  from  Poupart's  ligament.  It  is 
usually  oblong  and  rounded,  and  may  appear  uneven  or  lumpy  on 
closer  palpation  ;  it  is  not  tender  unless  the  caecum  itself  becomes 
inflamed.  It  has  a  doughy  consistency.  The  diagnosis  is  made  by  the 
situation  and  character  of  the  tumor,  and  the  absence  of  pain,  tender- 
ness, and  constitutional  symptoms,  and  by  its  disappearance  under  the 
influence  of  purgatives.  If  the  impaction  causes  a  localized  colitis,  or  so- 
called  typhlitis,  the  tumor  is  tense,  tender,  and  painful,  dull  on  percus- 
sion, the  dulness  being  sharply  limited  by  the  boundaries  of  the  ciecum. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     503 

In  intussusception  a  tumor  is  often  detected  in  the  right  lower  quad- 
rant or  to  the  right  of  the  navel.  It  is  generally  distinct,  of  the  shape 
of  the  bowel,  not  very  tender,  and  harder  than  the  tumor  of  appen- 
dicular inflammation.  The  diagnosis  from  the  latter  is  made  by  the 
difference  in  the  character  of  the  tumor,  by  the  pain  being  colicky  and 
recurring  in  paroxysms,  by  vomiting  and  constipation  being  more 
marked,  and  by  the  tenesmus  and  passage  of  blood  and  mucus  from 
the  bowel.  The  last-named  symptom  and  the  tumor,  with  a  constant 
desire  to  defalcate,  are  the  most  characteristic  features  of  intussuscep- 
tion. A  tumor  may  be  detected  within  the  rectum  by  digital  explora- 
tion, if  the  intussusception  is  low  down.  There  may  be  distinct  hemor- 
rhage, or  the  passage  of  the  invaginated  portion  of  the  bowel  per 
rectum.  Intussusception  is  the  most  frequent  cause  of  intestinal  ob- 
struction in  infants  and  young  children.  It  occurs  nearly  twice  as 
often  in  males  as  in  females.  Stercoraceous  vomiting  is  not  so  com- 
mon as  in  other  forms  of  acute  obstruction  of  the  bowel. 

In  pelvic  abscess  a  swelling  sometimes  makes  its  appearance  on  the 
right  side,  above  Poupart's  ligament.  It  is,  perhaps,  situated  more 
toward  the  median  line  than  perityphlitic  abscess,  and  it  is  less  defined 
than  the  tumor  of  typhlitis  ;  but  the  diagnosis  from  these  affections 
must  be  made  by  the  history,  which  is  usually  that  of  an  antecedent 
salpingitis,  or  of  previous  abortion  or  miscarriage.  Vaginal  examina- 
tion discovers  that  palpation  of  the  uterus  causes  pain  ;  that  the  uterus 
is  fixed,  instead  of  being  freely  movable;  and  that  the  pelvis  is  blocked 
up  by  an  exudate  on  the  affected  side. 

In  pelvic  hcematocele  a  tumor  may  form  in  the  lower  half  of  one  of 
the  lower  quadrants.  It  is  distinguished  from  appendicitis,  perityph- 
litic abscess,  and  pelvic  abscess  by  the  absence  of  fever  and  constitutional 
signs  of  suppuration  ;  from  perityphlitic  and  pelvic  abscess  by  its 
sudden  onset,  probably  at  a  menstrual  period  ;  by  the  less  degree  of 
tenderness,  and  by  the  anaemia  and  collapse  which  follow  its  appearance. 
It  is  almost  invariably  the  result  of  a  ruptured  extrauterine  pregnancy. 
Hence  it  may  be  preceded  by  the  passage  of  deoidua  and  the  objective 
signs  of  pregnancy.  From  pelvic  abscess  it  is  distinguished  by  its 
occurrence  in  a  woman  without  antecedent  tubal  or  uterine  disease, 
and  by  the  less  degree  of  tenderness  of  the  uterus  and  relative  absence 
of  fixation. 

In  stricture  of  the  ileo-coscal  valve  due  to  cancer  there  is  frequently  a 
tumor  in  the  right  lower  quadrant,  between  the  umbilicus  and  anterior 
superior  spinous  process  of  the  ilium,  or  between  the  latter  and  the  ribs. 
The  diagnosis  is  made  by  noting  the  fact  that  the  tumor  has  developed 
gradually,  that  the;  patient  lias  suffered  with  colicky  pain,  vomiting,  and 
constipation,  possibly  preceded  by  diarrhoea,  and  that  peristaltic  move- 
ments of  the  intestines  can  readily  be  seen  through  the  abdominal  walls. 
The  abdomen  at  the  site  of  the  tumor  is  somewhat  distended.  The 
tumor  itself  is  irregular  and  tender,  and  is  dull  on  percussion. 

The  disease  is  very  rare,  and  is  said  by  Fenwick  to  be  more  common 
in  women  from  twenty  to  forty  years  of  age. 

Fu-cal  abscess,  arising  from  ulceration  of  the  colon,  may  be  suspected, 
according  to  Fenwick,  when  there  is  a  localized  abdominal   -welling, 


504 


SPECIAL  DIAGNOSIS. 


immovable  in  respiration  or  by  moderate  amount  of  pressure  with  the 
fingers,  the  size  and  shape  being  altered  when  diarrhoea  occurs,  and 
when  percussion  over  the  tumor  gives  a  tympanitic  or  a  more  forcible 
stroke,  a  dull  sound,  or  when  an  emphysematous  sensation  is  commu- 
nicated to  the  fingers. 

In  tumors  of  the  right  ovary  there  is  at  first  a  gradual  enlargement  in 
the  right  groin,  unaccompanied  by  pain,  fever,  or  impairment  of  health 
until  the  tumor  has  attained  considerable  size.  They  are  usually 
cystic,  and  fluctuation  can  be  obtained.  The  tumor  is  dull,  and  by 
bimanual  examination,  with  the  fingers  of  one  hand  in  the  vagina,  the 
tumor  can  be  traced  into  the  broad  ligament,  and  the  displacement  of 
the  uterus  which  it  occasions  made  out.  The  cystic  ovarian  tumors 
grow  from  the  starting-point  in  the  directiou  of  an  axis  diagonally 
toward  the  median  line.  There  is  dulness  in  front  of  the  abdomen 
and  a  clear  percussion-note  or  tympany  in  the  flanks.      (Fig.  102.) 


Fig.  102. 


Position  of  an  ovarian  tumor  of  the  right  side,  in  various  stages  of  enlargement.  The  shading 
indicates  the  percussion-dulness  in  ovarian  dropsy  of  moderate  extent;  the  umbilical  region  is  dull 
from  the  presence  of  fluid,  and  the  flanks  remain  clear.  The  outer  circle  shows  a  further  extent 
which  the  dulness  may  reach  in  ovarian  dropsy.    (Bright.) 


In  the  Left  Lower  Quadrant.  Enlargements  in  this  region  are  due 
most  frequently  in  women  to  ovarian  tumors,  pelvic  abscess,  pelvic 
hosmatocele,  and  fibroids  of  the  uterus,  the  diagnostic  points  of  which 
have  been  referred  to  already  under  palpation  and  percussion  of  the 
right  iliac  region.  In  addition  to  the  affections  named,  enlargements 
are  occasionally  met  with  from  fgecal  accumulations  in  the  flexure  of 
the  colon,  cancer  of  the  descending  colon,  tubercular  peritonitis,  and 
enlargements  or  displacements  of  the  spleen  and  kidney  (q.  v.).  Faced 
abscess  also  may  occur  here,  and  the  tumor  of  intussusception  may  be 
detected  on  the  left  side. 

Palpation  and  Percussion  above  the  Pubis.  Enlargements 
in  this  region  may  be  due  to  fibroid  tumors  of  the  womb.  They  occur 
most  frequently  in  sterile  women,  and  are  accompanied  usually  by  hem- 
orrhage. Bimanual  examination  of  the  uterus  will  reveal  an  uneven- 
ness  of  surface  of  the  womb  if  the   tumor  is  external,  and  passage  of 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     505 

the  sound  will  detect  any  growth  projecting  into  the  cavity  of  the 
womb. 

The  enlargement  may  be  due  to  a  distended  bladder.  It  is  a  good 
rule  always  to  be  sure  that  this  viscus  is  empty  before  beginning  an 
examination. 

In  acute  tubercular  peritonitis  a  swelling  may  develop  in  this  region. 
It  appears  gradually,  is  diffused  aud  free  from  tenderness,  but  is  pre- 
ceded by  pain  and  fever.  There  is  no  palpable  tumor,  but  the  percus- 
sion-note is  dull  and  the  tension  is  increased.  Moreover,  the  level  of 
dulness  is  apt  to  vary  with  change  of  posture.  The  general  health  is 
markedly  affected,  loss  of  flesh  is  rapid,  and  diarrhoea  and  sweats  are 
common.      Another  focus  of  disease  may  be  discovered  in  the  lungs. 

Palpation  and  Percussion  of  the  Region  below  the  Ster- 
num. Enlargement  in  this  region  is  most  frequently  due  to  affections 
of  the  stomach  {q.  v.).  It  is  not  uncommon,  however,  to  find  here  a 
cancerous  nodule  projecting  from  the  surface  of  the  liver,  or  a  hydatid 
cyst  of  the  same  organ.  The  diagnosis  must  be  made  by  determining, 
with  the  aid  of  palpation  and  percussion,  whether  the  tumor  is  con- 
tinuous with  the  liver,  the  effect  of  respiration  upon  it,  and  its  apparent 
depth  from  the  surface,  tenderness,  fluctuation,  etc.,  and  by  a  study  of 
the  subjective  symptoms  pointing  to  disease  of  the  stomach  or  liver 
(see  Diseases  of  the  Liver). 

Much  more  rarely  enlargement  here  may  be  from  tumor  of  the  pan- 
creas, such  as  cyst,  abscess,  or  cancer.  According  to  the  studies  of  Fitz, 
the  former  is  marked  by  deep  seated  colicky  pain  occurring  in  parox- 
ysms, by  discharges  from  the  bowels  of  matter  resembling  saliva,  by 
the  detection  of  fat  in  the  stools  and  sugar  in  the  urine,  by  salivation, 
and  by  the  occurrence,  of  jaundice. 

Cancer  of  the  pancreas  is  recognized  by  the  detection  of  a  painful 
tumor  in  the  epigastrium.  The  pain  is  not  aggravated  by  the  taking 
of  food,  but  is  said  to  be  increased  by  the  erect  posture.  The  bowels 
are  constipated,  and  the  stools  may  or  may  not  be  fatty.  Emaciation 
is  progressive,  as  in  all  cancerous  affections,  and  in  the  last  stages  there 
may  be  occasional  vomiting  and  persistent  jaundice. 

Palpation  and  Percussion  of  the  Upper  Right  Quadrant 
is  limited  largely  to  an  investigation  of  changes  in  the  liver  and  gall- 
bladder, and  is  discussed  in  the  section  devoted  to  them. 

Palpation  and  Percussion  of  the  Upper  Left  Quadrant. 
Enlargement  in  this  region  is  generally  due  to  disease  of  the  spleen  (q.  v.). 
It  may  be  due  to  f cecal  accumulation  in  the  left  transverse  and  descend- 
ing colon.  This  condition  is  recognized  by  the  painlessness  and  doughy 
consistence  of  the  tumor,  and  by  careful  inquiry  as  to  the  condition  of 
the  bowels.  Constipation  will,  of  course,  exist,  but  both  patient  and 
physician  may  be  misled  by  apparent,  diarrhoea,  <>r  even  dysentery; 
there  will  be  fluid  or  semi-fluid  dejections  mingled  with  scybala,  and 
sometimes  mucus  and  blood. 

An  interesting;  cause  <>f  swelling  in  this  region,  and  in  the  Lumbar 
region,  is  perigastric,  or  subdiaphragmatic  abscess,  a  collection  of  pus 
walled  in  by  the  stomach,  spleen,  diaphragm,  colon,  and  the  abdominal 
walls. 


506  SPECIAL   DIAGNOSIS. 

The  most  common  cause  is  the  irritation  of  a  gastric  ulcer  which  has 
nearly  or  quite  perforated,  and  has  formed  adhesions  with  surrounding 
viscera.  This  was  the  cause  in  forty-one  out  of  fifty-two  cases  ana- 
lyzed by  Fenwick,  while  in  six  it  was  associated  with  cancer  and  in 
four  with  abscess  commencing  externally.  Pain  in  the  epigastrium  or 
abdomen  was  the  chief  subject  of  complaint,  and  in  most  of  the  cases 
there  was  dyspepsia,  sometimes  vomiting  It  is  singular  that  hoema- 
temesis  was  mentioned  in  only  two  cases.  Fenwick  thinks  that  in 
every  case  of  perigastric  abscess,  except  in  persons  affected  with  phthi- 
sis, cancer,  or  some  other  chronic  exhausting  malady,  the  first  forma- 
tion of  the  abscess  will  be  accompanied  by  either  collapse  and  signs  of 
general  peritonitis,  or  by  sudden  and  severe  pain  in  the  epigastrium, 
attended  with  indications  of  local  peritonitis. 

Fever  is  a  prominent  symptom,  but  physical  signs  are  absent.  A 
tumor,  according  to  the  same  author,  is  rarely  distinguishable  except 
when  the  cause  is  cancer.  It  is  dull,  but  afterward  tympanitic  on  per- 
cussion, and  not  movable  on  inspiration  or  external  pressure.  The 
tension  of  the  abdominal  muscles  prevents  successful  palpation.  There 
may  be  arching  outward  of  the  ribs.  The  displacement  of  surrounding 
viscera  will  depend  upon  the  size  of  the  abscess  and  the  extent  of 
adhesions.  The  diaphragm  is  pushed  upward,  and  dulness  may  extend 
as  high  up  as  the  angle  of  the  scapula.  In  this  case  a  pleural  effusion 
is  simulated.  Breathing  is  embarrassed  by  the  upward  pressure  upon 
the  lung  and  heart.  Sometimes,  when  gas  is  formed  in  connection 
with  the  abscess,  amphoric  sounds  on  auscultation  and  percussion  are 
heard  both  in  the  abdomen  and  over  the  thorax.  To  this  condition 
the  name  pyo-pneumothorax  subphrenieus  has  been  applied.  The  abdo- 
men then  becomes  tense,  tender,  prominent,  and  tympanitic  on  percus- 
sion. (See  p.  350  )  It  must  be  distinguished  from  left  pneumothorax. 
Air  in  the  pleural  cavity  pushes  the  left  wing  of  the  diaphragm  clown, 
and  hence  increases  the  area  of  percussion-dulness  and  the  palpability 
of  the  left  lobe  of  the  liver  and  spleen.  In  subdiaphragmatic  abscess 
with  gas,  the  liver  and  spleen  are  not  palpal  >le,  nor  can  their  area  be 
limited  by  percussion.  The  heart  is  dislocated  in  pneumothorax,  and 
its  area  tympanitic  on  percussion,  while  the  impulse  is  seen  in  the 
epigastrium  or  to  the  right  of  the  sternum.  In  subphrenic  pneumo- 
thorax the  heart  is  elevated,  and  the  impulse  seen  in  the  nipple-line. 
At  the  same  time  there  is  tympany  in  the  lower  half  of  the  cardiac  area 
of  dulness.  Pyo-pneumothorax  subphrenieus  must  not  be  mistaken  for 
dilatation  of  the  stomach. 

Palpation  and  Percussion  of  the  Loins.  Enlargements  in 
these  regions  may  be  due  to  affections  of  the  kidney  (q.  v.).  They 
may,  however,  be  due  to  enlargement  or  displacement  of  the  spleen 
ancl  liver  (q.  v ),  or  to  tumors  of  the  retro-peritoneal  glands.  On  the 
left  side  the  possibility  of  perigastric  abscess  must  be  borne  in  mind, 
as  sometimes  the  dulness  and  increased  tension  of  the  tumor  extend 
as  far  down  as  the  lumbar  region. 

Palpation  and  Percussion  about  the  Centre  of  the  Abdo- 
men. Umbilical  hernia,  cancers  of  the  stomach,  liver,  and  intestine,  hydatid 
cysts  of  the  liver,  and  tumors  of  the  gall-bladder,  together  with  floating 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM     507 

kidney,  spleen,  and  liver,  all  at  times  cause  tumors  which  may  be  felt  in 
this  region.  They  must  be  distinguished  from  each  other  by  methods 
already  referred  to  under  the  organs  named.  The  general  principle 
upon  which  to  proceed  is  to  endeavor,  by  palpation  and  percussion,  to 
discover  the  organ  to  which  the  tumor  belongs.  To  this  end  careful 
inquiry  should  be  made  as  to  the  time  the  tumor  has  been  known  to 
exist;  its  effect,  if  any,  upon  the  general  health;  its  effect  upon  the 
function  of  the  possible  organs  affected,  and  particularly  as  to  the 
presence  or  absence  of  vomiting,  constipation,  diarrhoea,  or  jaundice. 

Tumor  in  the  region  about  the  umbilicus  may  be  from  tubercular 
disease  of  the  mesenteric  glands  (tabes  mexenterica).  It  occurs  nearly 
always  in  children,  and  presents  the  physical  signs  and  symptoms  of 
tubercular  peritonitis,  with  the  addition  that  enlarged  mesenteric 
glands  may  sometimes  be  felt.  Children  grow  pale  and  anaemic,  waste 
away,  have  apparently  causeless  diarrhoea,  the  passages  being  foul  and 
the  food  undigested.  The  abdomen  is  large,  but  appears  larger  when 
compared  with  the  emaciated  body.  It  is  tender,  its  walls  are  thick- 
ened and  less  elastic  than  normal.  Signs  of  tubercular  disease  in 
other  organs  may  be  detected. 

Facts  gathered  in  this  way,  carefully  analyzed,  and  then  studied 
with  reference  to  the  physical  propert.es  of  the  tumor  (hard  or  soft, 
fluctuating,  doughy,  or  not),  will  generally  suffice  for  a  probable  diag- 
nosis. A  positive  diagnosis  often  cannot  be  made  at  the  first  exam- 
ination, and  sometimes  is  possible  only  after  watching  the  progress  of 
the  case  for  a  considerable  time. 

Diseases  of  the  Stomach. 

The  stomach  is  a  canal  in  which  the  food  is  detained  for  the  purpose 
of  solution.  Its  walls  are  made  up  of  mucous  membrane,  muscle,  and 
peritoneum.  It  is  richly  supplied  with  bloodvessels.  Because  of  its 
great  functional  activity  it  has  an  abundant  nerve-supply.  It  is,  more- 
over, surrounded  by  rich  plexuses  of  sympathetic  nerves,  through 
which  and  its  special  nerve,  the  pneumogastric,  it  is  in  intimate  rela- 
tion with  every  organ  of  the  body. 

The  Symptomatology.  The  local  .symptoms  of  disease  of  the  stomach 
arc  dependent  upon  :  (1)  The  morbid  process  which  affects  it  ;  (2)  the 
effect  of  the  process  upon  the  anatomical  structure  of  the  organ  (atro- 
phy, dilatation,  tumor)  whereby  the  size  is  affected  ;  (3)  the  effect  upon 
its  function. 

The  symptoms  due  (1)  to  the  morbid  process  are  not  different  from 
the  symptoms  of  similar  morbid  processes  elsewhere,  save  that  they  arc 
modified  by  the  function  of  the  organ  or  its  special  anatomy,  a  canal. 
Hence  congestions  are  attended  by  discharge  of  mucus;  inflammations 
are  attended  by  pain  and  by  a  now  of  mucus  and  pus  ;  ulcers  by  pain 
and  the  accidents  of  ulceration  (hemorrhage);  malignant  disease  by  pain 
and  swelling  (tumor),  and  its  accidents,  hemorrhage  and  obstruction  ; 
while  to  each  process  belong  the  general  phenomena  which  attend  it. 
But  the  stomach  is  highly  sensitive  and  resents  the  intrusion  of  disease 
or  of  that  which  (1)  causes  disease  or  (2)  irritates  the   affected    part. 


508  SPECIAL  DIAGNOSIS. 

Expression  of  this  resentment  is  shown  in  hyperaesthetie  symptoms  (see 
the  Neuroses),  as  pain  ;  in  the  abolition  or  derangement  of  function  ;  and 
in  the  great  pathological  reflex  act  of  the  stomach — vomiting.  It  will 
be  seen  later  that  this  may  be  a  symptom  of  every  local  morbid  process 
of  the  organ,  either  directly  because  of  the  disease  or  its  existing  cause, 
both  of  which  are  operative  in  irritant  inflammations  ;  or  indirectly 
because  the  process  has  set  up  undue  sensitiveness.  In  the  latter  instance 
any  material,  as  food,  which  the  stomach  is  accustomed  to  receive,  be- 
comes as  much  an  irritant  as  mucus,  pus,  or  blood. 

2.  The  niorbid  processes  modify  the  anatomical  structure  and  lead 
to  other  morbid  conditions,  as  we  see  when  dilatation  succeeds  inflam- 
mation or  obstruction  of  the  orifices.  Xow  the  symptoms  of  the  sec- 
ondary conditions  are  the  same  as  elsewhere — in  atrophy,  diminution 
in  size  ;  in  dilatation,  increase  in  size,  with  retention  and  fermen- 
tation, and  finally  discharge  of  the  contents  by  vomiting. 

3.  Functional  Symptoms.  Any  local  disease  of  the  stomach  must 
influence  its  function  ;  therefore,  conversely,  functional  symptoms  must 
be  present  in  all  local  diseases.  But  functional  disorder  may  be  present 
without  local  anatomical  change  ;  the  impairment  is  nearly  always 
induced  through  the  influences  of  the  nervous  system.  The  functions 
of  the  stomach  are  to  digest  and  to  absorb  the  products  of  digestion.  The 
former  function  is  motor  and  chemical,  the  completeness  of  which  de- 
pends upon  mixture  of  the  food  with,  and  solution  in,  the  gastric  juice. 
The  symptoms,  therefore,  must  be  due  to  changes  (1)  in  the  motor,  (2) 
in  the  secretory,  and  (3)  in  the  absorptive  functions  of  the  organ.  The 
functions  may  be  increased  or  diminished ;  the  former  are  the  primary 
and  usually  temporary  aberrations;  the  latter  succeed  the  former,  and 
are  permanent. 

Central  and  Reflex  Influences.  In  the  consideration  of  the  symp- 
tomatology of  gastric  diseases  the  anatomical  relations,  by  its  vascular 
and  nervous  connection,  must  be  considered.  The  student  is  sufficiently 
familiar  with  physiology  and  pathology  to  know  that  each  organ  has 
a  representative  in  the  central  nerve-mass,  the  brain,  and  that  disease 
in  one  organ  will  influence  the  function  and  create  morbid  symptoms 
in  another  which  is  related  to  it  through  intimate  nervous  connec- 
tions. 

The  central  representative  or  centre  is  influential  in  proportion  to 
the  power  and  activityof  its  peripheral  adjunct.  It  is,  moreover,  influ- 
enced by  higher  centres,  the  psychical,  and  it  in  turn  modifies  them. 
It  influences  or  modifies  lower  centres,  (1)  functional,  (2)  vasomotor, 
(3)  motor,  or  (4)  sensory.  The  result  of  this  mechanism  is  :  1.  That 
functional  alteration  or  organic  disease  of  (a)  the  gastric  centre,  or 
(6)  of  centres  of  higher  control,  or  (c)  of  the  nerve  that  connects  the 
centre  and  the  organ — pneumogastrfc  nerve— produces  gastric  symp- 
toms. 2.  That  gastric  diseases  produce  symptoms  in  other  organs,  as 
palpitation  (reflex).  3.  That  disease  of  other  organs  produces  gastric 
symptoms  or  disease,  as  the  vomiting  of  pregnancy,  or  renal  calculus, 
or  disease  of  the  testicle,  or  the  gastritis  of. nephritis.  Thus  vomiting 
is  caused  by  emotion  (high  centre),  influencing  the  pneumogastric 
(lower  centre)  ;  by  a  tumor  pressing  or  destroying  the  pneumogastric 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     509 

centre;  or  by  a  tumor,  as  aneurism,  pressing  on  the  pneumogastric 
nerve.  I  have  taken  the  simplest  illustration.  When  we  come  to  the 
study  of  gastric  neuroses  the  extraordinary  influences  of  the  nervous 
mechanism  will  be  appreciated  ;  or,  when  hysteria  is  studied,  the 
physiology  of  its  extreme  gastric  symptoms  will  be  recognized.  To 
continue  with  vomiting  :  when  its  mechanism  and  clinical  course  are 
studied  it  will  be  found  to  be  due  to  affections  of  the  blood,  the 
poisons  of  which  irritate  cerebral  centres  or  nerve  plexuses  in  the 
stomach. 

But  gastric  diseases  also  arise  because  of  the  vascular  supply.  Thus, 
in  heart  disease  with  venous  stases  the  gastric  veins  become  the  seat  of 
congestion  with  consequent  gastric  catarrh.  Or  hepatic  disease  will 
cause  portal  congestion  and  gastric  catarrh. 

It  is  observed,  therefore,  in  unravelling  the  symptomatology  of 
gastric  disease,  we  must  first  note:  (A)  The  objective  symptoms  due 
(1)  to  morbid  processes,  (2)  to  alterations  of  function,  (3)  to  altera- 
tions of  size.  (B)  The  subjective  symptoms  due  (1)  to  morbid  pro- 
cesses, (2)  to  alterations  of  function,  (3)  to  alterations  of  size  (sense 
of  fulness,  etc.). 

Further  Examination.  In  addition  to  the  examination  of  the  stom- 
ach in  order  to  judge  correctly  of  the  nature  of  gastric  lesions  as  indi- 
cated above,  we  must  ascertain  (1)  whether  the  gastric  symptoms  are 
dependent  upon  disease  of  other  organs — particularly  the  eye,  nose,  and 
genitalia,  the  heart  and  kidneys — by  an  examination  of  each  organ; 
and  (2)  whether  other  symptoms  are  created  by  gastric  disease. 

Toxic  Symptoms.  The  toxic  symptoms  arising  in  gastric  disease  are 
worthy  of  a  few  words.  They  are  nervous  symptoms  due  to  the  ab- 
sorption of  ptomaines  or  imperfect  products  of  assimilation.  If  absorp- 
tion of  the  toxines  takes  place  suddenly  and  in  large  amounts,  coma 
and  convulsions  occur  ;  or,  if  gradually,  hypochondriasis,  melancholia, 
mental  depression,  with  vasomotor  phenomena  of  various  kinds,  arise. 

Diagnosis  from  Disease  of  Contiguous  Organs  Functionally  Related. 
The  student  will  soon  learn  that  diseases  of  the  stomach  which  arc 
functional  in  character  cannot  be  differentiated  with  ease  from  diseases 
in  other  organs  functionally  related.  He  will  find  that  to  draw  hard- 
and-fast  lines  between  gastric  and  intestinal  indigestion,  or  between 
so-called  disordered  gastric  and  hepatic  function,  is  impossible.  Organs 
which  are  closely  related  in  physiological  function,  and  which  have 
nerve-  and  blood-supply  in  common,  cannot  be  differentiated  when  dis- 
ordered function  is  considered.  Hence  indigestion  and  biliousness,  or 
simple  acute  gastritis  and  duodenitis,  are  beyond  the  pale  of  close  dis- 
crimination.     In  fact,  the  symptoms  of  each  blend  in  a  manner. 

The  Data  Obtained  by  Observation.     The  Objective  Symptoms. 

Now,  one  of  the  objective  expressions  of  the  morbid  process  or  oi 
altered  function  is  seen  in  changes  in  the  character  of  the  contents  of 
the  stomach.  The  contents  are  obtained  for  examination  when  dis- 
charged from  the  stomach  (vomit)  or  when  removed  artificially  (wash- 
ings).    Both  fluids  are  .studied  by  inspection,  including  microscopical 


510  SPECIAL  DIAGNOSIS. 

examination,  by  smelling,  and  by  chemical  and  bacteriological  exam- 
ination. Alteration  of  function  is  also  seen  in  alteration  of  digestion, 
and  is  estimated  by  chemical  and  physiological  methods.  The  activity 
of  the  digestion  must  be  determined  by  ascertaining  the  duration  of 
digestion  and  its  degree  of  completeness,  which  depend  upon  three 
factors  :  (1)  The  motor  power;  (2)  the  absorptive  power;  (3)  the  diges- 
tive power  of  the  gastric  secretions. 

To  secure  objective  data,  therefore,  the  following  is  necessary  : 

I.  Physical  examination,  to  determine  tenderness  and  the  size,  posi- 
tion, movement  (peristalsis)  of  the  stomach. 

II.  Examination  of  the  gastric  contents. 

III.  Examination  of  the  digestive  power  of  the  stomach. 

IV.  Examination  of  the  motor  power  of  the  stomach. 

V.  Examination  of  the  absorptive  power  of  the  stomach. 

I.  Physical  Examination  of  the  Stomach.  Inspection. 
Direct  inspection  of  the  stomach  region  rarely  affords  much  positive 
information.  When  there  is  much  loss  of  abdominal  fat  and  the  stomach 
is  well  distended  its  outlines  can  sometimes  be  traced  with  the  eye. 
The  best  position  is  behind  and  above  the  patient's  head  while  he  is 
lying  down.  If  the  lower  curvature  can  be  traced  considerably  below 
the  navel,  the  stomach  is  almost  certainly  dilated,  and  if,  at  the  same 
time,  there  is  a  prominent  swelling  in  the  pyloric  region,  accompanied 
by  progressive  loss  of  weight  and  cachexia,  the  dilatation  is  probably 
due  to  cancer  of  the  pylorus.  A  marked  groove  extending  from  the 
umbilicus  to  the  ribs,  about  or  to  the  left  of  the  nipple-line,  is  seen  in 
cases  of  dilatation  when  the  stomach  has  fallen.  It  is  the  position  of 
the  lesser  curvature.  The  lower  border  is  also  marked  by  a  groove 
extending  in  a  curve  from  the  pubis  toward  the  first  groove. 

Peristaltic  waves  may  be  seen  with  the  naked  eye,  or  brought  into 
view  by  the  use  of  the  ether  spray  or  faradism.  When  the  pylorus  is 
obstructed  anti-peristaltic  waves  may  also  be  seen.  The  waves  of 
muscular  contraction  begin  at  the  cardiac  end  or  fundus,  and  extend 
to  the  pylorus  ;  hence  they  begin  under  the  ribs  of  the  left  side  and 
extend  downward  toward  the  right  lower  quadrant.  They  vary  in 
extent  with  the  amount  of  dilatation. 

An  endoscope  has  been  adapted  to  inspection  of  the  stomach  ;  but 
such  an  instrument  necessarily  can  be  in  the  hands  of  but  few,  and  it 
would  be  difficult  to  persuade  American  patients  to  permit  its  use. 

Distention  of  the  stomach  with  carbonic  ox:de  (see  Percussion)  or  air 
frequently  brings  the  outlines  of  tumors  of  the  pylorus  plainly  into 
view,  while  at  the  same  time  any  tumor  lying  behind  the  stomach  be- 
comes less  distinct,  and  false  tumors  due  to  spasm  of  the  gastric  mus-» 
cular  coat  vanish.  Distention  also  helps  to  map  out  the  whole  stomach 
and  to  separate  it  from  surrounding  viscera. 

Gastro-diaphony  or  Transillumination  of  the  Stomach.  Einhorn  has 
succeeded  in  transilluminating  the  stomach  by  an  Edison  lamp  fastened 
to  a  soft-rubber  tube.  The  wires  to  the  battery  are.  carried  through 
the  tube.  After  the  stomach  contents  have  been  removed  the  patient 
is  to  take  one  or  two  glassfuls  of  water.  The  apparatus  after  lubrica- 
tion is  then  inserted.    The  examination  must  be  made  in  a  dark  room. 


DISEASES  OF  STOMACH,  INTESTINES,  AXD  PERITONEUM.     q\\ 

By  means  o£  gastrodiaphony  the  position  and  size  of  the  stomach  are 
determined,  to  a  certain  exteut,  and  the  preseDce  of  tumors  of  the 
anterior  wall  of  the  stomach  is  recognized.  The  results  are  not 
strictly  accurate,  however,  as  transillumination  of  the  intestines  is 
brought  about  if  they  are  empty.  The  form  and  size  of  the  stomach 
are  not  so  readily  brought  out  as  the  topographic  relation  of  tumors 
of  the  stomach  and  those  in  the  vicinity  of  that  organ.  It  is  of  service 
in  some  cases  to  distinguish  dilatatiou  from  gastroptosis. 

Palpation.  Palpation  of  the  stomach  is  closely  associated  with  aus- 
cultation, inasmuch  as  the  former  also  elicits  sounds  (succussion,  gurg- 
ling) which  are  helpful  in  diagnosis.  The  hand  must  be  placed  flat  upon 
the  abdomen  and  pressure  made  by  bending  the  ends  of  the  phalanges. 
To  make  deep  palpation  gradually  increasing  pressure  with  a  rotary 
movement  must  be  employed.  It  may  be  of  advantage  to  palpate  in 
the  knee-elbow  position  so  that  deeply  seated  tumors,  if  movable,  may 
fall  to  the  abdominal  wall  (see  Auscultation). 

But  palpation  elicits  information  independently  of  auscultation, 
chiefly  in  conditions  of  disease.  Epigastric,  pulsation  is  common  in 
anaemia  ;  in  nervous  dyspepsia  ;  in  valvular  disease  of  the  heart,  par- 
ticularly tricuspid  regurgitation,  producing  a  liver-pulse  ;  and,  more 
rarely,  iu  aneurism  of  the  abdominal  aorta. 

Increased  resistance  may  be  due  to  the  hypertrophy  of  the  muscular 
coat  which  coexists  witli  distention  of  the  stomach.  When  the  stom- 
ach is  shrunken  and  the  resistance  increased,  it  may  be  due  to  a  diffuse 
carcinoma  of  the  walls  of  the  stomach  ;  or  rarely,  to  the  so-called 
"  fibroid  stomach,"  the  atrophy  and  thickening  of  the  walls  being- 
due  to  chronic  gastritis. 

Increased  resistance  limited  to  the  pylorus  is  found  in  carcinoma. 
The  same  effect  produced  by  a  tense  right  rectus  muscle  must  be 
excluded. 

Position  of  Gastric  Tumors.  Cancers  of  the  pylorus  are  situated 
usually  between  the  xiphoid  cartilage  and  the  umbilicus,  frequently  a 
little  to  the  right  of  the  median  line;  but  they  may  be  found  below  the 
umbilicus,  and,  exceptionally,  still  lower  down.  Adhesious  to  neighbor- 
ing organs  commonly  prevent  the  tumor  from  being  moved.  When  it 
has  formed  adhesions  to  the  liver  or  diaphragm  it  moves  with  respira- 
tion. 

As  a  rule,  tumors  due  to  gastric  cancer  are  small,  hard,  and  irreg- 
ular, and  gradually  increase  in  size. 

( )ther  non-malignant  tumors  are  occasionally  found,  and  also  tumors 
due  to  adhesions  around  old  ulcers,  and  to  puckered  scars.  The  latter 
are  distinguished  from  cancerous  tumors  not  by  the  sense  of  touch,  but 
by  their  duration  and  clinical  history. 

The  most  exact  method  of  determining  the  position  and  size  of  the 
stomach  is  by  internal  exploration  combined  with  external  palpation. 
A  bougie  is  introduced  into  the  stomach  and  swept  over  its  entire  inter- 
nal surface',  the  position  of  the  bougie  being  followed  from  point  to 
point  by  the  palpating  hand. 

This  method  is  not  advisable  when  it  is  possible  to  make  a  diagnosis 
without  it,  and  is  contraindicated,  according  to  Boas,  by  the  following 


512  SPECIAL  DIAGNOSIS. 

general  diseases  :  Heart  disease  with  failing  compensation  ;  angina 
pectoris  ;  aneurisms  of  large  vessels  ;  recent  hemorrhages  of  whatever 
kind  ;  phthisis  in  progressive  stage  ;  emphysema  with  bronchial  catarrh 
in  progressive  stage  ;  apoplexies,  complete  or  incomplete  ;  hyperseniias 
of  the  brain  ;  pregnancy;  continued  or  remittent  fever;  great  cachexia. 

It  is  also  contraindicated  by  the  following  diseases  of  the  stomach  : 
Ulcer  with  antecedent  hsematemesis  or  black  stools;  dilatation  of  stom- 
ach with  typical  vomiting;  palpable  cancer  of  pylorus,  with  emaciation, 
coffee-ground  vomit  and  the  other  classical  symptoms  of  cancer;  in  many 
neuroses  of  the  stomach  in  which  the  character  of  the  disease  is  clearly 
established  by  the  rest  of  the  symptoms;  in  acute  gastric  or  intestinal 
catarrh  associated  with  fever  ;  when  the  mucous  membrane  of  the 
stomach  bleeds  easily.  Slight  capillary  hemorrhages  constitute  no 
co  n  trai  n  dication . 

It  will  be  seen  from  the  above  list  that  the  method  has  a  limited 
raDge  of  applicability. 

Pain  and  Tenderness.  Tenderness  is  elicited  by  palpation  in  gas- 
tritis, in  dyspepsia,  especially  the  catarrhal  form,  in  ulcer,  and  in 
cancer.  In  gastritis  and  dyspepsia  the  tenderness  is  usually  diffuse 
aud  is  not  constant ;  in  cancer  the  tenderness  is  usually  limited  to  the 
seat  of  the  tumor,  but  is  not  so  marked  nor  so  sharply  localized  as  in 
ulcer.  In  ulcer  tenderness  is  rarely  absent ;  even  when  there  is  no 
pain,  it  is  very  decided,  and  is  so  localized,  sometimes,  that  it  can 
be  covered  with  the  tip  of  the  finger.  Pain  in  the  stomach  from 
ulcer  is  chronic,  circumscribed,  and  variously  described  as  burning 
and  wound-like.  It  is  aggravated  by  palpation,  and  by  food  or 
drink,  especially  hot  stimulating  drinks,  and  relieved  by  cold,  sooth- 
ing drinks.  '  It  is  accompanied  frequently  by  pain  in  the  corresponding 
vertebrae. 

Diffuse  pain  is  met  with  in  acute  and  chronic  gastritis,  and  in  cancer 
of  the  stomach-walls. 

Percussion.  Position  of  the  Stomach.  The  stomach  does  not 
occupy  a  fixed  position,  and  is  a  distensible  organ.  It  is  depressed 
by  downward  pressure  of  the  diaphragm  in  deep  inspiration,  by  em- 
physema, left  pleural  effusions,  enlargements  of  the  liver  and  spleen, 
and  tight  lacing  ;  it  is  raised  by  any  causes  which  greatly  distend  the 
bowels  or  peritoneal  cavity — tympanites,  peritoneal  effusions,  tumors, 
etc.  Moreover,  after  food  is  taken,  the  stomach  is  distended  and  its  posi- 
tion changed,  being  rotated  anteriorly  from  below,  the  greater  curva- 
ture rising  and  looking  more  forward,  while  the  anterior  surface  has 
a  more  upward  presentation. 

The  cardiac  orifice  of  the  stomach  is  fixed  by  its  passage  through 
the  diaphragm  and  by  peritoneal  attachments  which  it  receives  there. 
It  is  behind  the  sternal  insertion  of  the  left  seventh  rib.  The  pylorus, 
on  the  contrary,  is  freely  movable  when  the  stomach  is  empty  ;  it  is 
nearly  in  the  median  line,  but  when  the  stomach  is  full  it  is  pushed 
several  inches  to  the  right  ;  it  lies  between  the  right  sternal  and  para- 
sternal lines,  on  a  level  with  the  tip  of  the  xiphoid  cartilage. 

Obrastzow  (Deut.  Arch,  fur  hlin.  Medicin,  Bd.  xliii.  5,  417-456) 
divides  the  space  between  the  navel  and  the  xiphoid  cartilage  into 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     513 

three  equal  parts,  and  says  that  the  lower  border  of  the  stomach,  both 
in  men  and  in  women,  is  in  the  lower  or  supra-umbilical  third. 

In  children  under  fifteen  years  the  lower  border  rarely  extends  to  the 
umbilical  line  ;  after  fifty  years,  on  the  contrary,  it  often  extends  below 
the  navel.      In  conditions  of  bad  nutrition  it  falls  nearly  to  the  navel. 

According  to  Pacanowski  and  Wagner,  the  upper  border  of  the 
stomach,  in  the  left  parasternal  line,  lies  at  the  lower  border  of  the 
fifth  rib  or  in  the  fifth  intercostal  space,  rarely  at  the  fourth  rib  or  in 
the  sixth  intercostal  space.  In  the  left  nipple-line  it  lies  from  the  fifth 
interspace  to  the  sixth  rib,  occasionally  in  the  fourth  interspace  or  at 
the  seventh  rib.  In  the  anterior  axillary  line  it  lies  at  the  lower  border 
of  the  seventh  or  eighth  rib,  rarely  above  the  sixth  rib,  never  under 
the  eighth  rib. 

Traube  has  called  special  attention  to  the  left  lower  portion  of  the 
thorax  which  projects  over  the  stomach,  "  the  half- moon-shaped  space." 
The  upper  limit  is  a  crescentic  line  starting  from  the  sternum  in  the 
sixth  interspace  and  extending,  in  a  curved  line  corresponding  approxi- 
mately to  the  curve  of  the  rib,  to  the  axillary  line.  It  is  known  as 
' '  Traube' s  line. ' '  In  health  this  space  gives  a  tympanitic  note,  unless 
the  stomach  or  transverse  colon  is  full,  or  the  omentum  very  fatty.  In 
left  pleural  effusion  it  is  dull  (see  Diseases  of  Lungs). 

A  part  of  the  anterior  portion  of  the  stomach  and  its  lower  border 
can  be  determined  by  percussion.  Ordinarily,  the  most  suitable  posi- 
tion for  examining  the  stomach  is  the  recumbent  one,  with  the  knees 
drawn  up  so  as  to  relax  the  abdominal  muscles. 

The  stomach  contains  air  at  all  times,  but  the  amount  varies  greatly. 
The  percussion-note  is  tympanitic,  high  in  pitch,  frequently  with  a 
metallic  ring  ;  its  quality  is  peculiar — "  stomach  tympany." 

The  percussion-area  of  the  stomach  is  increased  (1)  by  causes  ex- 
ternal to  the  stomach  ;  contraction  of  the  liver,  old  pleurisy  with 
retraction  of  lung,  emphysema,  former  pregnancies,  bad  nutrition,  and 
tumors  pulling  down  the  stomach  ;  (2)  by  intrinsic  causes  ;  distention 
of  the  stomach. 

Conversely,  the  percussion-area  is  diminished  by  causes  external  to 
the  stomach  ;  enlargement  of  the  liver  and  spleen,  left-sided  pleural 
effusion,  pneumothorax,  and  hypertrophy  of  the  heart. 

Actual  diminution  in  size  of  the  stomach  itself  is  difficult  to  demon- 
strate clinically  with  certainty.  If  upon  inflation  the  great  curvature 
remains  at  a  higher  level  than  3  to  5  cm.  above  the  umbilicus,  diminu- 
tion in  size  is  highly  probable.  But  even  then  the  lower  border  may 
be  prevented  from  descending  by  adhesions  to  surrounding  viscera. 

Enlargement  of  the  stomach  is  generally  due  to  dilatation,  and  is 
besl  marked  clinically  by  a  low  position  of  the  greater  curvature. 
Dilatation  of  the  stomach,  according  to  Boas,  can  be  separated  from 
descent  of  the  organ  only  when  the  greater  curvature  is  more  or  less 
below  the  level  of  the  navel,  and  when  the  greatest  height  of  the 
stomach  exceeds  10-14  cm.  (4  to  5|  inches)-  But  descent  and  dilata- 
tion are  frequently  present  together.  It  must  not  be  forgotten  that 
when  there  is  descent  the  normal  tympany  is  lowered  and  the  tym- 
panitic area  above  the  ribs  is  replaced  by  dulness. 

33 


514  SPECIAL  DIAGNOSIS. 

Auscultatory  percussion  is  a  most  satisfactory  method  of  determin- 
ing the  borders  of  the  stomach  and  its  size.  Its  area  can  readily  be 
denned  from  that  of  the  liver,  spleen,  and  colon  :  first,  with  the  stomach 
normal  ;  second,  inflated  by  gas  ;  third,  filled  with  liquid.  It  is  well 
to  determine  the  results  in  the  recumbent  posture,  and  then  in  the  up- 
right so  as  to  determine  if  the  stomach  falls  from  its  normal  position. 
Liquid  may  be  injected  through  the  stomach- tube,  or  the  patient  may 
drink  successive  portions,  percussion  being  employed  after  each  amount 
(eight  ounces)  taken.  After  the  site  of  the  dulness  is  fixed,  have  the 
patient  lie  down.  The  fluid  falls  backward  and  the  air  in  the  stomach 
conies  anteriorly  ;  the  dull  note  is  replaced  by  a  tympanitic  note.  The 
change  is  a  sign  the  fluid  is  in  the  stomach  and  serves  to  distinguish 
stomach  from  colon  tympany.  The  force  required  for  percussion 
should  be  very  light ;  indeed  a  fillip  with  the  nail  is  sometimes  suffi- 
cient. It  may  even  be  well  to  allow  the  blow  to  glance  from  the  sur- 
face, as  the  perpendicular  stroke  brings  out  the  general  abdominal 
resonance.  The  use  of  coins  is  sometimes  of  advantage.  In  dilatation 
of  the  stomach  the  percussion-note  sometimes  varies  in  tone  over  the 
viscus  from  dull  to  tympany,  or  vice  versa,  because  the  organ  contracts 
under  the  influence  of  the  blows.  Some  have  described  a  clinking 
percussion-sound,  not  unlike  that  of  the  "cracked  pot, "  over  the  thorax. 

In  order  to  separate  stomach  tympany  from  that  of  the  colon,  which 
resembles  it,  the  stomach  may  be  distended  with  gas,  while  the  colon 
contains  solid  or  liquid  matter  ;  or,  if  the  colon  be  filled  with  gas,  the 
patient  may  be  allowed  to  stand  and  drink  a  glass  or  two  of  water. 
In  either  case  the  contrast  between  a  dull  and  a  clear  note  marks  the 
boundary  between  stomach  and  colon. 

Ziemssen  recommends  carbonic  acid  (developed  by  mixing  sodium 
bicarbonate  and  tartaric  acid)  to  distend  the  stomach  ;  the  quantity  em- 
ployed for  adult  men  is  seven  grammes  of  bicarbonate  of  soda  and  six 
grammes  (one  and  oue-half  drachms)  of  tartaric  acid.  Adult  women 
should  receive  one  gramme  less  of  each. 

As  carbonic  acid  sometimes  causes  an  uncomfortable  oppression,  ordi- 
nary air  is  preferred  by  some.  It  can  be  forced  in  by  a  hand-bulb 
syringe  attached  to  an  ordinary  stomach-tube.  The  percussion-note 
over  tumors  of  the  pylorus  is  imperfectly  tympanitic.  Welch  describes 
it  as  "  tympanitic  dulness."  Less  frequently  it  is  dull,  and  rarely  it 
is  flat. 

Auscultation.  Auscultation  can  determine  whether  or  not  there 
is  obstruction  at  the  cardiac  orifice.  On  listening  over  the  oesophagus 
with  the  stethoscope,  when  the  patient  is  swallowing  a  liquid,  a  spurting 
sound  is  heard,  i  olio  wed  in  from  five  to  ten  or  twelve  seconds  by  a 
second  sound  which  marks  the  escape  of  the  fluid  from  the  cardiac 
orifice  of  the  oesophagus  into  the  stomach,  so-called  "deglutition-mur- 
mur." When  there  is  obstruction  of  the  cardiac  orifice  the  second 
sound  may  be  delayed  as  long  as  a  minute. 

When  the  stomach  is  partly  filled  with  fluid  a  succussion  or  splashing 
sound  can  be  produced  by  moving  the  patient  quickly  from  side  to 
side,  or  by  quickly  compressing  the  stomach  and  allowing  it  to  rebound 
again  immediately.     Such  sounds  are  abnormal  if  they  are  heard  long 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     515 

after  digestion  should  be  completed  and  the  stomach  empty.  The  ear 
need  not  be  applied  to  the  body,  but  kept  near  by  while  the  move- 
ments are  made. 

Normally,  after  drinking  fluids,  a  splashing  sound  is  not  developed 
lower  than  the  umbilical  line.  If  it  is  heard  below  this  line,  it  is  an 
indication  of  dilatation  or  of  deep  position  of  the  whole  stomach. 
Dilatation  is  very  probable  if  the  splashing  sound  is  heard  below  the 
navel  in  a  fasting  stomach. 

Furthermore,  this  sound  is  a  sign  of  atony.  If  50  to  100  grammes 
of  water  be  swallowed,  no  splashing  sound  is  heard  unless  there  is 
atony  of  the  stomach-walls  ;  but,  if  the  atony  is  pronounced,  a  smaller 
quantity  will  be  sufficient  to  develop  the  sound.  It  is  to  be  remem- 
bered that  the  splashing  sound  of  itself  does  not  indicate  disease. 
It  is  significant  only  when  taken  with  other  signs,  and  also  when  it  is 
found  after  more  than  one  examination. 

II.  Examination  of  the  Gastric  Contents.  Either  the  con- 
tents are  secured  with  a  stomach-tube  or  the  vomitus  is  examined. 

Mode  of  Procedure.  1.  A  test-breakfast  (Ewald),  or  a  test-dinner 
(Leube),  is  administered,  or  the  fasting  stomach  contents  removed. 
EwakVs  Test-breakfast :  It  consists  of  one  or  two  ounces  (35  grammes) 
of  bread  and  a  cup  of  tea  (£  litre),  or  the  same  amount  of  water. 
Leube-Riegel  test-dinner:  A  large  plate  of  soup  (400  c.c),  a  large 
portion  of  beefsteak,  or  other  meat,  some  potatoes  and  a  roll  are  taken, 
and  examination  is  made  three  or  four  hours  after  the  meal  (see  Boas' 
Meal.  Lactic  Acid).  2.  Remove  the  contents  of  the  stomach  one  hour 
after  breakfast  is  taken,  by  aspiration  or  by  expression.  Aspiration  con- 
sists in  the  withdrawal  of  the  stomach-contents  by  suction;  either  with 
the  ordinary  stomach-pump,  by  means  of  a  bottle  exhausted  of  air,  as 
employed  for  paracentesis,  and  connected  with  the  stomach-sound,  or 
by  connecting  the  sound  with  a  hand-ball  aspirator  or  Politzer  bulb. 

Expression  consists  in  compression  by  the  abdominal  muscles,  as  if 
straining  in  defecation.  The  patient  takes  a  deep  inspiration  and  then 
contracts  the  muscles  as  above.  If  the  tube  is  long  enough,  it  can  be 
bent  so  as  to  assist  expression  with  siphonage. 

Aspiration  is  less  disagreeable  to  the  patient,  and  is  necessary  when 
the  stomach- contents  are  not  fluid  enough  to  flow  easily,  but  it  is  sub- 
ject to  much  the  same  contraindications  as  obtain  in  the  case  of 
exploration  of  the  oesophagus  and  stomach  (see  page  484). 

Expression  is  not  to  be  employed  when  there  are  old  ulcers,  ulcerat- 
ing carcinoma,  phthisis  with  antecedent  haemoptysis,  or  a  disposition 
to  menorrhagia. 

These  methods  supply  the  most  reliable  information  of  the  condition 
of  the  stomach  and  its  secretions;  because,  when  once  withdrawn,  the 
character  of  the  secretions  can  be  ascertained  accurately  aud  the  quan- 
tity measured;  moreover,  being  able  to  choose  the  time  of  examination, 
we  can  decide  whether  or  not  what  is  found  corresponds  with  health, 
and  if  not,  in  what  particular  it  indicates  disease.  These  methods  per- 
mit a  diagnosis  to  be  made  before  other  methods  supply  sufficient  data. 

A  soft-rubber  tube,  with  two  good-sized  openings  near  its  distal 
extremity,  should  be  selected.     Stockton  suggests  a  tracing  of  rings 


516  SPECIAL  DIAGNOSIS. 

around  the  tube  one  inch  apart,  beginning  twenty  inches  from  and  end- 
ing thirty  inches  from  the  lower  extremity,  for  the  purpose  of  measur- 
ing the  length  of  the  tube  inserted.  In  healthy  adults  the  distance 
from  the  incisor  teeth  to  the  lower  border  of  the  stomach  is  about 
twenty-two  inches.  In  dilatation  it  may  be  from  twenty-four  to  thirty. 
The  distance  is  partly  determined  by  success  in  the  siphonage.  If  the 
return  flow  of  fluid  does  not  take  place,  it  is  well  either  to  withdraw 
the  tube  or  push  it  further  on  ;  for,  if  too  long,  it  may  curve  above  the 
level  of  the  fluid,  or,  if  too  short,  it  may  not  reach  the  fluid. 

After  the  tube  is  oiled,  or  coated  with  the  white  of  an  egg,  the 
patient  should  be  seated,  and  the  tube  at  once  passed  to  the  back  of 
the  pharynx,  and,  with  or  without  guiding  by  the  finger,  pushed 
toward  the  oesophagus.  It  is  at  once  grasped  by  the  oesophagus  or 
lower  pharynx,  and,  if  the  patient  is  instructed  to  swallow  and  to 
breathe  slowly,  it  is  rapidly  carried  downward  by  deglutition.  Mucus 
that  accumulates  in  the  mouth  after  the  tube  is  passed  should  be 
allowed  to  dribble  outward,  and  not  be  swallowed.  It  is  often  of 
advantage  to  reassure  the  patient  by  having  him  pronounce  the  letter 
"a"  or  some  small  syllable.  It  is  not  necessary  to  extend  the  head 
backward.  The  tube  is  then  attached  to  the  apparatus  used  for  para- 
centesis, or  to  a  tube  entering  a  bottle  in  which  a  vacuum  is  created 
by  an  ordinary  rubber  bulb  apparatus  ;  or  to  the  aspirator  of  Boas, 
which  is  a  modification  of  the  ball-syringe.  A  valve  is  placed  between 
the  stomach- sound  and  the  syringe. 

If  a  hard  tube  is  used,  it  must  be  guided  by  the  operator,  who  should 
stand  back  of  the  patient,  supporting  the  head,  which  should  not  be 
thrown  too  far  backward.  The  tube  can  be  passed  by  the  operator 
seated  in  front  of  the  patient.  This  kind  of  tube  is  used  with  the 
stomach-pump. 

Normal  Gastric  Contents.  The  amount  of  fluid,  after  diges- 
tion of  a  test-breakfast  has  continued  for  one  hour,  is  from  30  to  40 
c.c.  After  filtering  the  filtrate  is  clear,  yellow  or  yellowish-brown  in 
color.  If  the  digestion  is  normal,  the  fluid  should  contain  free  hydro- 
chloric acid,  and  no  lactic  acid.  It  should  also  contain  pepsin,  rennin 
(the  milk-curdling  ferment),  and  organic  acids.  Albuminoids  should 
be  converted  into  albumoses  and  peptone,  and  starches  into  achro- 
odextrin,  dextrose,  or  maltose. 

Physical  and  Chemical  Examination.  The  steps  taken  are 
as  follows  : 

A.  Physical  examination  : 

1.  The  reaction. 

2.  The  odor. 

3.  The  character  and  quantity.     Inspection. 

B.  Chemical  examination. 

It  is  to  be  observed  that  perfect  familiarity  with  the  products  of, 
and  the  length  of  time  required  by  normal  digestion,  is  very  essential. 

1.  Reaction.  The  normal  reaction  of  the  contents  of  the  stomach 
is  usually  acid,  from  the  hydrochloric  acid  of  the  gastric  juice.  It 
may  be  alkaline  in  cases  of  hemorrhages,  or  in  the  vomiting  known  as 
waterbrash. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     517 

2.  Odor.  The  odor  is  soar  normally,  but  it  may  be  aromatic  from 
the  presence  of  the  fatly  acids,  fsecal  in  obstruction  of  the  bowels  with 
fsecal  vomiting,  and,  finally,  may  indicate  the  uature  of  poisonous 
ingesta — ammonia,  phosphorus,  carbolic  acid. 

3.  Inspection  of  the  Stomach-contents.  By  ordinary  inspec- 
tion the  quantity  and  the  character  of  the  vomitus  or  stomach  contents 
are  noted.  With  the  aid  of  the  microscope  the  various  micro-organisms 
are  sought  for.  In  this  manner  most  valuable  information  as  to  the 
digestive,  motor,  and  absorptive  power  is  ascertained.  JSTot  only  do  we 
learn  whether  digestion  has  taken  place  or  not,  but  also  the  variety  of 
food  that  is  undigested — albuminoids  or  hydrocarbons. 

The  Quantity.  Fasting  Stomach.  If  a  person  has  taken  no  food  or 
drink  between  the  evening  meal  and  the  following  morning,  the  stomach 
should  not  contain  more  than  three  and  one-half  fluidounces  ;  more 
than  this  is  abnormal  (see  p.  518). 

The  Character.  By  it  we  learn  the  digestive  power.  If  undigested 
food  is  found  after  digestion  should  be  normally  completed,  there  is 
deficient  digestive  energy.  No  undigested  food  should  be  found  longer 
than  six  or  seven  hours  after  an  ordinary  meal  of  mixed  foods. 

Digestive  Power.  Boas  states  that  an  abnormally  great  quantity 
of  solid  matter  and  small  amount  of  chyme  indicate  an  abnormal 
retention  of  the  latter,  which  is  usually  brought  about  by  motor  weak- 
ness (atony,  dilatation  of  the  stomach),  or  dilatation  in  conjunction 
with  insufficient  absorptive  power.  Sometimes,  when  there  is  a  large 
residue  in  the  stomach,  the  contents  separate  into  three  layers.  The 
uppermost  is  mucus  or  undigested  food  ;  the  second,  generally  the 
thickest  layer,  consists  of  fluid;  and  the  lowest  layer  is  chyme.  Such 
a  formation,  he  says,  points  to  abnormally  long  retention  as  the  result 
of  stenosis  and  consecutive  dilatation,  or  to  motor  weakness. 

The  stomach  should  be  empty  much  sooner  if  only  starches  are 
taken,  as  in  Ewald's  test-breakfast.  One  hour  after  the  administra- 
tion of  a  test-breakfast  of  35  grammes  of  white  bread  and  300  grammes 
of  water  there  should  remain  40  c.c.  Hence  if,  after  such  a  breakfast, 
there  is  found  a  much  greater  quantity,  then  motor  or  absorptive  in- 
sufficiency may  be  considered  to  exist.  A  filtrate  of  100  to  300  c.c.  is 
very  probably  due  to  organic  obstruction  to  the  outflow,  stenosis  of  the 
pylorus,  adhesions,  or  dislocation  of  the  pylorus.  Of  course,  to  make 
sure  that  the  stomach  contains  nothing  at  the  time  of  giving  the  break- 
fast, it  must  first  be  emptied.  The  character  of  the  food  taken  is 
observed,  as  undigested  particles  may  be  seen  in  the  contents. 

Vomiting  and  Regurgitation.  Regurgitation  of  food  from  the  oesoph- 
agus can  be  told  from  vomiting  by  the  appearance  of  muscle-fibre, 
if  it  had  been  taken.  If  it  is  vomited,  the  fibre  is  in  a  process  of 
disintegration  ;  if  not,  it  is  whole. 

Mucus  is  found  in  small  quantity  normally,  but  is  increased  in 
catarrhal  affections  of  the  mouth,  throat,  or  stomach.  When  its  source 
is  the  mouth,  saliva  also  is  generally  present.  Mucus  is  recognized  by 
its  stringy,  tenacious  character.  Chemicrd  diagnosis.  Add  the  mucus,, 
gently  shaking,  to  cold-water;  pour  oft'  the  supernatant  water;  add  a 
little  liquor  potassa?.      The  mucus  is  dissolved  by  the  alkali.      To  the 


518  SPECIAL  DIAGNOSIS. 

solution  add  acetic  acid;  a  precipitate  is  formed  which  is  insoluble  in 
an  excess  of  acetic  acid.  In  this  manner  mucus  is  distinguished  from 
the  precipitate  of  syntonin,  as  the  latter  is  soluble  in  an  excess. 
Pigmented  mucus  in  vomitus  is  usually  from  the  bronchial  tubes. 

Bile  and  intestinal  juice  may  be  regurgitated  into  the  stomach  as  the 
result  of  violent  emesis,  or  when  the  pylorus  is  much  relaxed,  or  in 
stenosis  of  the  duodenum  below  the  common  duct;  bile  is  then  present 
in  large  quantity  if  the  stomach  is  dilated.1  Bile  is  recognized  by  the 
usual  tests  (see  under  Examination  of  Urine),  and  intestinal  juice  by 
its  peculiar  properties  and  the  presence  of  leucin  and  tyro-in. 

Blood  is  found  in  ulcer  ;  cancer  ;  acute,  especially  toxic,  gastritis  ; 
injuries  to  the  mucous  membrane  from  the  use  of  the  sound  for  expres- 
sion, and  violent  retching.  It  is  also  common  in  cirrhosis  of  the  liver, 
and  may  occur  in  purpura,  peliosis  rheumatica,  the  hemorrhagic  diath- 
esis, and  in  yellow  fever.  Blood  mixed  with  gastric  mucus  may  come 
from  the  lung,  the  act  of  coughing  having  excited  vomiting. 

If  the  blood  is  unaltered,  it  can  be  distinguished  from  all  other  sub- 
stances by  microscopic  examination.  Occasionally  the  blood  has  the 
appearance  of  coffee-grounds.  The  hemorrhage  has  taken  place  slowly 
under  these  circumstances.  In  fact,  the  more  rapid  the  bleeding  the 
brighter  the  red  color  of  the  blood.  The  hcemin  test  serves  to  distin- 
guish it.  The  suspected  material  is  filtered  and  a  little  of  the  nitrate 
evaporated  in  a  watch-glass  ;  when  dry  a  small  portion  is  mixed  with 
finely  pulverized  salt  upon  a  glass  slide  ;  it  is  then  covered  with  a 
cover-glass  and  one  or  two  drops  of  glacial  acetic  acid  allowed  to  flow 
under  the  cover-glass.  The  acetic  acid  is  evaporated  by  slowly  heating 
the  slip  over  a  small  flame,  and  when  dry  a  few  drops  of  water  are 
allowed  to  flow  under  the  cover-glass  to  dissolve  the  salt.  If  the 
vomit  contained  blood,  brown  rhombic  crystals  of  haemin  (hydrochlorate 
of  haeinin)  will  appear  under  the  microscope.  As  they  are  very  small, 
a  magnification  of  about  300  diameters  will  be  necessary  to  bring  them 
readily  into  view.  The  guaiacum  test  may  be  fallacious,  as  the  same 
color-reaction  takes  place  when  bile  or  saliva  or  a  starch,  like  potato,  is  in 
the  test-liquid.  It  is  performed  as  follows  :  Add  two  or  three  drops  of 
the  tincture  of  guaiacum  to  a  small  portion  of  the  gastric  contents  in  a 
test-tube  and  pour  ozonic  ether  on  the  surface.  When  the  liquids  meet  a 
blue  color  develops.  Bile  may  be  distinguished  from  blood  by  Gmelin's 
test  for  the  former — color-reaction  with  nitric  acid.  If  blood  is  present 
in  the  stomach-contents,  it  may  be  detected  by  the  test  for  iron.  To 
the  gastric  contents,  "  coffee-grounds,"  in  a  porcelain  capsule,  add  a 
small  quantity  of  potassium  chlorate  and  a  few  drops  of  a  strong  acid, 
HC1.  Heat  over  a  flame  and  add,  a  few  drops  of  a  5  per  cent, 
solution  of  potassium  ferrocyanide.  If  iron  is  present,  Prussian  blue 
is  formed. 

Pus  is  rarely  present  in  sufficient  quantity  to  be  detected  by  the 
naked  eye,  but  it  sometimes  occurs  in  phlegmonous  gastritis  and  when 
an  abscess  has  ruptured  into  the  stomach.  In  microscopic  amounts  it 
may  be  found  in  severe  catarrhal  affections.      Pus  may  be  in  the  vom- 

1  Hochhaus:  Berlin,  klin.  Woeh.,  1891,  No.  17. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     519 

itus  and  yet  come  from  the  lungs.      It  is  usually  a  muco-pus,  and  is 
told  by  the  pigmented  pellets  or  strings  of  muco-purulent  material. 

Fcecal  matter  is  vomited  in  complete  obstruction  of  the  bowels,  and, 
according  to  "Vierordt,  in  severe  diffuse  peritonitis.  It  is  recognized 
partly  by  its  appearance  and  partly  by  its  odor. 

Worms  are  sometimes  vomited  ;  the  round  worms  not  so  very  unf  re- 
quently  ;  oxyurides  and  ankylostomata  rarely. 

Microscopical  Examination.  The  illustration  (Fig.  103)  shows  the 
various  matters  which  may  be  found  in  vomited  matter.  Briefly,  • 
they  are  columnar  and  squamous  epithelium  ;  white  blood-corpuscles 
acted  on  by  gastric  juice  ;  red  blood-corpuscles.  The  corpuscles  are 
usually  isolated.  The  red  are  rarely  perfect,  and  in  the  white  little 
more  than  the  nucleus  remains.      From  the  food  we  may  also  find 


Fig.  103. 


Microscopical  appearance  oi  stomach-contents. 

1,  red  blood-corpuscles ;  2,  leucocytes ;  3,  squamous  epithelium  ;  4,  fat-globules ;  5,  starch-gran 

ules;  5',  starch  changed  by  action  of  the  gastric  juice;  6,  muscular  fibre;  7,  sarcinse  ventriculi : 

8,  fat-crystals ;  9,  piece  of  orange  ;  10.  phosphatic  crystal ;  11,  yeast  fungi ;  12,  bacilli  and  micrococci. 


muscle-fibres,  fatty  globules  and  fat  needles,  elastic  fibres  and  con- 
nective tissue,  starch-granules,  and  vegetable  cells.  Muscle-fibres  are 
recognized  by  their  transverse  striation.  Fat-globules  are  soluble  in 
ether,  and  are  recognized  by  their  refracting  powers.  Starch-granules 
stain  blue  with  iodo-potassic -iodide  solution. 

In  addition, fungi  of  many  forms  are  found,  as  the  mould-fungi; 
the  yeasts  (torula?),  and  fission-fungi.  The  latter  are  recognized  after 
staining  by  the  iodo-potassic-iodide  solution,  which  colors  them  blue. 
The  most  important  fission-fungi  are  the  sarcinse  ventriculi.  They  are 
of  a  dark  gray  tint,  stain  mahogany-brown  to  reddish  brown  with  the 
above-mentioned  solution,  and  resemble  in  shape  corded  bales  of  goods 
(see  Bacteriological  Diagnosis).  The  torulce  and  x<ir<-in<r  arc  present 
when  fermentation  is  in  progress,  and  hence  indicate  delayed  diges- 
tion from  motor  insufficiency  or  deficient  digestive  energy. 


520  SPECIAL  DIAGNOSIS. 

B.  Chemical  Examination.  A  chemical  examination  is  made 
to  determine  (1)  the  presence  of  free  acids;  (2)  the  total  degree  of 
acidity  of  the  stomach  contents;  (3)  the  presence  of  free  HO;  (4) 
the  presence  of  lactic  acid  ;  (5)  the  presence  of  volatile  acids;  (6)  the 
presence  of  products  of  digestion  ;  (7)  the  presence  of  pepsin  ;  (8) 
the  presence  of  rennin;  (9)  the  carbo-hydrates.  Hydrochloric  acid  is 
the  normal  acid  of  the  gastric  juice.  Normally  lactic  acid  is  found 
during  the  first  half-hour  of  digestion,  when  starches  have  been  taken. 
When  only  meats  have  been  taken  lactic  acid  is  not  found  early  in 
digestion.  The  secretion  of  hydrochloric  acid  is  not  delayed  until 
then,  but  is  at  first  combined,  and  cannot  be  detected  as  free  acid 
until  half  or  three-quarters  of  an  hour  afterward. 

1.  Free  acids.  The  most  sensitive  test  for  free  acids  is  Congo  red. 
Filter-paper  soaked  in  a  saturated  solution  of  the  dye  and  allowed  to 
dry  is  turned  a  deep  blue  if  free  acid  is  present.  Prepared  with  a 
weak  solution,  the  filter-paper  is  turned  to  a  light  blue  by  HO,  and 
violet  by  organic  acids.  Wolff l  was  able  to  detect  one  part  of  HO 
in  20,000  parts  of  water.  When  no  reaction  is  obtained,  therefore, 
entire  absence  of  acidity  may  be  assumed. 

Benzo-purpurin  test-papers  are  made  as  follows  :  Soak  strips  of  filter- 
paper  in  a  saturated  solution  of  benzo-purpurin  and  dry.  They  are 
purple.  If  hydrochloric  acid  is  present,  they  are  turned  dark  blue. 
The  color  is  not  removed  by  shaking  with  ether.  If  organic  acids 
(butyric  or  lactic)  are  present,  it  is  turned  brownish-black,  but  the 
color  is  removed  by  shaking  with  ether.  Von  Jaksch  states  that  if 
hydrochloric  acid  and  the  organic  acids  are  present,  a  brownish-black 
color  is  also  produced,  hence  the  dark  blue  and  the  volatile  brownish- 
black  reactions  only  are  important. 

The  presence  of  free  acids,  as  indicated  by  the  Congo-red  or  beuzo- 
purpurin  tests,  shows  that : 

a.  HO — inorganic  acid — may  be  present  alone. 

b.  Lactic,  butyric,  or  acetic  acid — organic  acids — one  or  all,  may  be 
present  without  HO. 

c.  HO  and  one  or  more  of  the  organic  acids  may  be  present. 
Free  acidity  may  be  due  (1)  to  fixed  acids — hydrochloric  or  lactic  acid, 

fixed  acidity ;  (2)  to  volatile  acids — butyric  or  acetic  acid,  volatile  acidity. 

2.  The  Total  Acidity .  This  is  determined  by  titration.  The  stomach- 
contents  must  be  well  shaken ;  if  there  is  mucus  in  excess,  it  must  be 
strained  off  through  coarse  muslin.  Fdl  a  Mohr's  burette  with  a 
decinormal  solution  of  caustic  soda.2  To  10  c.c.  of  the  gastric  fluid 
add  two  drops  of  a  saturated  alcoholic  solution  of  phenol-phthalein. 
Allow  the  caustic-soda  solution  to  drop  slowly  from  the  burette  into 
the  fluid,  until  the  red  color  which  is  produced  does  not  disappear  on 
shaking.  The  color  is  produced  by  the  action  of  the  alkali  on  the 
phenol-phthalein.  Four  to  six  c.c.  of  the  caustic  soda  solution  are 
required  to  neutralize  the  acid  in  normal  digestion.     The  degree  of 

1  Trans.  Phila.  Co.  Med.  Soc,  1889,  x.  305. 

2  Decinormal  solution  of  sodium  hydrate  is  of  the  strength  of  4  grammes  of  pure  sodium 
hydrate  to  the  litre  of  distilled  water.  The  sodium  hydrate  must  be  pure,  and  made  from  sodium. 
This  weight  of  sodium  hydrate  (4  grammes)  will  exactly  neutralize  3.65  grammes  of  hydrochloric 
acidj 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     521 

acidity  is  expressed  in  percentage.  Thus  if  4  c.c.  neutralize  10  c.c., 
the  total  acidity  Avill  amount  to  40  per  cent.,  or  if  6  c.c.  are  required, 
to  60  per  cent,  of  the  normal. 

If  more  or  less  than  the  amount  just  indicated  of  the  alkaline  solu- 
tion is  required  to  neutralize  the  acid,  the  total  acidity  is  increased  or 
diminished,  and  hence  is  abnormal. 

Martin  recommends  the  following  modification  of  the  above  :  "  To 
20  c.c.  of  the  stomach- contents  add  three  or  four  drops  of  a  saturated 
alcoholic  solution  of  phenol-phthalein,  and  dilute  with  water  to  300  c.c. 
Place  150  c.c.  of  this  mixture  in  each  of  two  flasks,  and  place  them 
side  by  side  on  a  sheet  of  white  paper.  To  one  of  the  flasks  add  deci- 
normal  solution  of  sodium  hydrate  until  a  red  color  appears  ;  the  exact 
time  of  appearance  can  be  determined  by  comparison  with  the  liquid 
in  the  other  flask.  When  a  pinkish  tinge  appears  the  acid  liquid  is 
neutralized.    A  control  estimation  may  be  made  with  the  second  flask." 

Ewald's  method  of  expressing  the  total  acidity  is  by  a  number.  The 
number  is  the  same  as  the  quantity  of  decinormal  sodium  hydrate 
solution  requisite  to  neutralize  100  c.c.  of  the  gastric  contents.  Thus, 
if  50  c.c.  of  the  soda  solution  neutralized  100  c.c.  of  the  stomach- 
contents,  the  acidity  of  the  latter  would  be  expressed  by  the  figure  50. 
The  figures  can  be  converted  into  terms  of  hydrochloric  acid,  as  a 
decinormal  solution  of  sodium  hydrate  is  a  liquid  of  a  constant  strength, 
100  c.c.  of  which  exactly  neutralize  0.365  gramme  of  hydrochloric 
acid.  It  may  be  expressed  in  terms  of  hydrochloric  acid.  If  50  e.c. 
of  decinormal  sodium  hydrate  are  required  to  neutralize  100  c.c.  of 
the  stomach-contents,  this  would  be  equal  to  0.18  gramme  per  cent, 
hydrochloric  acid,  as  3.65  grammes  hydrochloric  acid  are  neutralized 
by  the  4  grammes  of  soda  in  a  litre  (1000  c.c.)  of  the  decinormal  solution. 

3.  Free  Hydrochloric  acid.  The  gastric  contents  are  now  filtered. 
Tropceolin  00  is  declared  by  Boas  to  be  an  absolutely  certain  test  for 
HC1.  A  saturated  alcoholic  solution  is  of  an  orange-yellow  color.  Three 
or  four  drops  of  it  are  placed  in  a  white  porcelain  dish  and  spread  upon 
the  sides  by  rotating  it.  The  same  amount  of  the  fluid  to  be  tested  is 
then  allowed  to  trickle  down  the  sides  of  the  dish  and  intimately  mixed 
with  the  tropreolin.  (Or  evaporate  the  dye  to  dryne-s,  and  then  add 
the  suspected  liquid.)  Upon  heating  the  dish  over  a  small  flame 
splendid  lilac-blue  to  blue  streaks,  characteristic  of  HC1,  will  appear 
if  that  acid  is  present.     No  organic  acid  gives  the  same  color. 

Tropaeolin  paper  is  turned  brown  by  gastric  juice  containing  HC1, 
the  brown  changing  to  blue  upon  the  paper  being  heated.  Organic 
acids  give  a  brown  color  also,  but  it  disappears  upon  heating. 

Phloroglucin  vanillin,  introduced  by  Giinzburg,  is  also  a  very  sensi- 
tive test  for  HO.  The  following  combination  is  said  by  Boas  t<>  be 
more  sensitive  than  the  ordinary  one,  which  contains  only  30  grammes 
of  absolute  alcohol  : 

Phloroglucin 2.0  (s?r.  xxx). 

Vanillin 1.0  (gr.  xv). 

Alcohol  (SO  per  cent.)  ........    100.0  (fjiij). 

Three  drops  are  put  into  a  porcelain  dish  and  an  equal  quantity  of 
the  stomach  filtrate.     Upon  cautious  heating  over  a  small  flame  a  beau- 


522  SPECIAL  DIAGNOSIS. 

tiful  carmine  surface  is  formed,  especially  at  the  edges.  The  same 
color  is  not  produced  by  inorganic  ac'ds.  Filter-paper  soaked  in  it 
and  moistened  with  a  few  drops  of  stomach-nitrate,  containing  HC1, 
changes  on  heating  to  a  beautiful  carmine,  which  is  unaltered  upon  the 
addition  of  ether.  Giinzburg's  original  test  is  employed  with  the  same 
solution,  except  that  30  grammes  of  alcohol  are  used.  One  drop  of. 
the  solution  and  one  drop  of  the  fluid  to  be  examined  are  evaporated 
to  dryness  on  a  water  bath.  The  appearance  of  a  rose -red  color  indi- 
cates the  presence  of  hydrochloric  acid. 

Congo-red  Test.  Boas'  method  is  a  modification  of  that  of  Mintz. 
Ten  c.c.  of  the  gastric  fluid  are  shaken  with  100  c.c.  of  ether  until 
organic  acids  are  removed.  The  Congo-red  test  is  then  employed  until 
the  grayish-blue  discoloration  cannot  be  secured. 

Boas'  Resorcin  Test  Dissolve  5  grammes  of  resorcin  and  3  grammes 
of  cane-sugar  iu  100  c.c.  of  weak  spirit.  Apply  the  test  in  exactly 
the  same  way  as  Giinzburg's.  A  similar  rose-red  coloration,  if  free 
hydrochloric  acid  be  present,  is  produced.  It  is  the  cheapest  solution 
that  can  be  employed. 

Caution.  In  testing  for  the  presence  of  HC1  it  is  better  to  give  the 
patient  a  meal  which  is  known  to  be  digestible  within  a  certain  time  by 
stomachs  in  a  normal  state,  otherwise  HC1  may  appear  to  be  absent 
because  it  is  still  combined  with  albuminoids.  Ewald's  test-breakfast 
is  the  simplest.  In  one  hour  the  contents  of  the  stomach  may  be 
aspirated  and  tested  for  HC1. 

Amount  of  Free  HCl.  If  by  previous  tests  HC1  is  found  alone,  its 
percentage  is  easily  calculated.  To  a  measured  quantity  of  the  gastric 
fluid  add  drop  by  drop  from  a  burette  a  decinormal  alkaline  solution 
until  the  acid  is  neutralized.  One  c.c.  of  the  alkaline  solution  is  equiv- 
alent to  0.003646  HCl.  Multiply  the  number  of  c.c.  required  to 
neutralize  10  c.c.  of  the  gastric  solution  by  0.003646,  and  again  by 
10,  the  result  will  be  the  percentage  of  acidity.  If  6  c.c.  are  used, 
the  percentage  will  be  6  X  0.003646  X  10  =  0.218,  within  the  normal 
range,  which  is  from  0.14  to  0.24  per  cent.  Giinzburg's  test  can  be 
used  to  estimate  the  quantity  of  HCl  This  is  applied  by  diluting  the 
stomach-contents  until  the  test  is  not  responded  to.  In  health  the 
limit  of  response  is  found  when  one  part  of  HCl  is  found  in  20, 000 
parts  of  the  fluid.  In  abnormal  conditions,  when  the  gastric  fluid  is 
diluted  one-half,  the  proportion  is  2  to  20,000,  or  1  in  10,000.  If  the 
fluid  is  diluted  to  ten  times  its  original  strength,  it  is  10  to  20,000, 
or  1  in  2000. 

4.  Lactic  Acid.  If  the  stomach-contents  are  colorless,  apply  the 
following  tests  ;  if  they  are  yellowish,  make  an  ethereal  extract,  as 
described  below,  and  then  use  the  tests.  Its  presence  may  be  deter- 
mined by  Uffelmann's  reagent:  Mix  one  drop  of  pure  carbolic  acid 
with  five  drops  of  a  dilute  solution  of  neutral  ferric  chloride.  Add 
sufficient  water  to  render  the  whole  of  an  amethyst-blue  color.  To 
this  add  a  few  drops  of  the  gastric  fluid.  A  mere  trace  of  lactic 
acid  will  change  the  blue  to  a  light  yellow  or  greenish  yellow.  The 
test  for  lactic  acid  is  simulated  when  phosphates,  glucose,  or  alcohol 
is  present  in  the  gastric  juice.     The  lactic  acid  should  be  removed 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     523 

by  extracting  with  ether,  as  follows:  50  e.c.  of  gastric  contents  are 
reduced  to  10  e.c.  by  heat  in  an  evaporating-dish  over  a  water-bath. 
After  the  concentrated  solution  cools  add  50  e.c.  of  ether.  The  vola- 
tile acids  are  driven  off  by  heat,  the  lactic  acid  is  dissolved  by  ether,  and 
hydrochloric  acid  remains  in  the  residue.  Apply  the  test  for  lactic 
acid  to  the  ethereal  extract  if  it  is  acid.  The  following  is  more  deli- 
cate :  add  one  drop  of  liq.  ferri  perchloridi  to  50  c.  c.  of  water ;  add 
suspected  solution  ;  a  drop  of  lactic  acid  causes  a  yellow  coloration. 

Boas  uses  the  following  :  /When  a  substance  containing  lactic  acid  is 
heated  with  oxidizers  such  as  manganese  dioxide  and  sulphuric  acid 
the  lactic  acid  is  decomposed  into  formic  acid  and  acetic  aldehyde  ; 
the  latter  is  detected  by  the  formation  of  iodoform  with  an  alkaline 
solution  of  iodine  ;  peptone  and  alcohol,  which  react  similarly,  are 
eliminated  by  concentrating  the  filtrate  to  a  syrup.  As  carbohydrates 
also  yield  aldehyde  when  treated  with  oxidizers,  a  Avatery  solution  of 
an  ethereal  extract  of  the  condensed  gastric  filtrate  of  a  trial-meal  free 
from  lactic  acid  must  he  used. 

5.  The  Volatile  Acids.  These  acids  are  best  detected  by  their  smell, 
their  volatility,  and  their  reaction. 

Butyric  Acid  is  recognized  by  the  pungent  odor  of  rancid  butter 
given  off  when  the  stomach-contents  are  evaporated.  It  is  recognized 
by  the  following  reaction  :  To  a  small  quantity  of  the  liquid  add  a 
small  quantity  of  alcohol,  and  two  drops  of  strong  sulphuric  acid; 
heat  for  a  short  time ;  a  characteristic  smell  of  butryic  ether,  like  that 
of   "  pineapple  rum"  is  given  off. 

Butyric  acid  is  also  detected  by  Uffelmann's  reagent.  A  few  e.c. 
of  the  filtered  gastric  fluid  are  shaken  with  three  or  four  times  the 
amount  of  ether.  The  ether  is  poured  off  Avhen  it  rises  on  the  top, 
and  fresh  ether  added  and  the  washing  repeated.  After  the  third 
washing  the  ether  that  cannot  be  poured  off  is  evaporated  by  means 
of  a  water-bath.  Add  a  few  drops  of  water  to  the  residue  and  then  an 
equal  amount  of  the  reagent.  The  characteristic  color  is  produced. 
It  strikes  a  tawny  yellow  color  with  a  reddish  tinge.  As  much  as  one 
part  of  the  reagent  in  2000  is  required. 

In  addition  to  Uffelmann's  test  the  volatile  acids  maybe  detected  by 
boiling  a  few  e.c.  in  a  test-tube  over  the  mouth  of  which  blue  litmus- 
paper  is  attached.  If  acid  is  present,  its  vapor  will  change  the  blue 
to  red.  Acetic  acid  is  recognized  by  its  odor,  particularly  after  heat- 
ing the  solution.  It  may  be  detected  as  follows :  Secure  an  ethereal 
extract  of  the  gastric  contents  (as  above),  evaporate  in  a  water-bath, 
and  dissolve  the  residue  in  water.  Neutralize  the  watery  solution  with 
sodium  carbonate,  and  then  add  neutral  ferric  chloride  solution.  A 
blood-red  color  results  if  acetic  acid  is  present. 

Alcohol  is  detected  by  its  odor,  and  by  Lichen's  iodoform-test. 
Distil  the  stomach-contents,  add  to  a  portion  a  small  quantity  of  liquor 
potassse,  and  then  a  few  drops  of  iodine-iodide  of  potassium  solution. 
A  precipitate  of  iodoform  takes  place  slowly  if  alcohol  is  present.  If 
acetone  is  present,  it  forms  rapidly. 

6.  The  Products  of  Digestion.  The  ultimate  products  of  digestion 
are  the  albumoses  and  peptones.      If  they  are  present  in  the  stomach- 


524  SPECIAL  DIAGNOSIS. 

contents,  it  shows  that  hydrochloric  acid  and  pepsin  must  have  been 
secreted  in  the  stomach.  If  vomiting  occurs  soon  after  food  is  taken, 
or  if  there  is  obstruction  at  the  lower  end  of  the  oesophagus,  these 
products  are  not  present.  Syntonin  is  a  product  of  digestion  which 
precedes  the  two  above  given.  To  ascertain  if  digestion  has  taken 
place,  it  is  necessary  only  to  test  for  syntonin  and  then  employ  the  biuret 
test.  Syntonin  is  detected  by  neutralizing  the  gastric  contents  with  a 
solution  of  sodium  hydrate.  The  precipitate  is  syntonin,  which  is 
soluble  in  an  excess  of  alkali,  and  may  be  again  precipitated  by  an 
alkali.  After  filtration  and  removal  of  the  syntonin  albumoses  and 
peptone  are  detected  by  the  biuret  test. 

7.  Pepsin.  If  HC1  is  present,  add  5  c.c.  of  a  gastric  nitrate  to  a 
small  piece  of  egg-albumin.  Allow  digestion  to  take  place  for  several 
hours  at  37°  to  40°  C.     Non-digestion  indicates  absence  of  pepsin. 

If  HC1  is  absent,  pepsinogen  is  found  alone.  Add  two  drops  of  a 
25  per  cent.  HC1  solution  to  10  c.c.  of  the  gastric  contents.  Add  to 
this  solution  a  small  portion  of  egg -albumin.  If  it  is  dissolved,  pep- 
sinogen was  converted  into  pepsin  by  HC1. 

8.  Rennin  (the  milk-curdling  ferment).  This  may  be  detected  as 
follows  :  From  5  to  10  c.c.  of  cow's  milk  of  neutral  reaction  is 
boiled  and  added  to  neutralized  and  filtered  gastric  juice.  Place  the 
mixture  on  a  warm  bath  heated  to  30°  or  40°  C.  The  casein  of  the 
milk  is  precipitated  in  flakes  in  from  twenty  to  thirty  minutes  if  the 
ferment  is  present. 

9.  The  Carbohydrates.  Add  a  few  drops  of  Lugol's  solution  to 
the  gastric  contents.  If  starch  is  present,  it  turns  blue.  If  erythro- 
dextrin,  it  .becomes  purple.  If  the  digestion  has  proceeded  so  far  as 
to  change  starch  into  dextrose,  the  iodine  hue  remains  unchanged. 
The  starches  should  be  completely  digested  an  hour  after  they  are  taken 
into  the  stomach,  hence  in  health  the  iodine  hue  should  not  change 
after  this  time. 

III.  The  Digestive  Power.  Giinzburg  has  introduced  the  use 
of  iodide  of  potassium  in  the  following  way:  From  three  to  five  grains 
are  placed  in  a  rubber  tube  with  extremely  thin  walls  ;  the  ends  of  the 
tube  are  then  bent  and  brought  into  apposition  with  each  other  and 
fastened  in  that  position  with  three  fibrin  threads  made  firm  by  preser- 
vation in  alcohol.  The  whole  packet  is  then  pressed  into  an  empty 
gelatin  capsule  and  given  to  a  patient  to  swallow  one-half  hour  after  a 
test-breakfast.  The  saliva  is  tested  for  iodine  every  fifteen  minutes. 
The  more  rapid  the  solution  of  the  capsule  and  fibrin  threads,  the  sooner 
the  iodine  can  be  absorbed  and  appear  in  the  saliva,  and  hence  this 
rapidity  is  an  index  of  the  digestive  energy. 

The  method  is  liable  to  fallacies  :  -solution  of  the  fibrin  may  take 
place  in  the  intestine  instead  of  the  bowel,  and  the  threads  may  be 
loosened  by  the  acids  of  fermentation  instead  of  by  digeston.  Never- 
theless the  test  is  a  valuable  one,  especially  when  aspiration  is  inad- 
missible. 

The  digestive  power  can  be  estimated  by  ascertaining  (1)  the  pres- 
ence of  gastric  juice  and  (2)  its  activity. 

1.    The  Gastric  Juice.     Wash  out  the  fasting  stomach  with  400  c.c. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     525 

of  lukewarm  water  :  test  by  litmus-paper  for  neutrality,  then  inject 
50  c.c.  of  a  3  per  cent,  solution  of  soda.  Allow  the  solution  to  remain 
twelve  minutes  and  then  remove  by  washing  out  the  stomach  with 
400  c.c.  of  water.  If  HC1  is  normal,  the  soda  solution  is  neutralized. 
If  the  HC1  secretion  is  deficient,  the  solution  remains  alkaline.  The 
presence  of  pepsin  is  then  to  be  determined. 

Test  for  the  Activity  of  the  Gastric  Juice.  After  boiled  white  of 
egg  has  been  taken,  remove  the  stomach-contents  one-half  hour  later. 
The  stomach  should  be  empty  before  the  egg  is  taken.  The  white  of 
one  or  two  eggs  should  be  boiled  in  four  ounces  of  water  and  then 
administered  ;  the  residue  removed  will  show  if  digestion  is  complete, 
and  albumoses  and  peptones  may  be  tested  for  by  the  biuret  reaction. 

Test  for  the  A  ctivity  of  the  Gastric  Juice  and  of  the  Movements  by  a 
Test-meal.  Ewald's  test-breakfast  must  be  employed  if  the  patient 
cannot  bear  more  solid  food,  otherwise  Leube's  test-meal  should  be 
used.  If  digestion  is  normal,  the  stomach-contents  removed  from  five 
to  seven  hours  after  a  test-meal  are  neutral  and  contain  a  fewT  flakes  of 
mucus.  At  the  end  of  five  hours  the  stomach-contents  are  acid  and 
contain  peptone,  some  undigested  muscle-fibres  and  starch-grains.  If 
the  stomach  contains  undigested  food  at  the  end  of  seven  hours,  the 
contents  are  acid  and  contain  peptones,  indicating  delay  in  digestion. 

IV.  The  Motor  Power.  Ewald  and  Sievers  have  suggested 
the  use  of  salol  ;  fifteen  grains  are  given,  and  normally  salicylic  acid 
should  be  detected  in  the  urine  in  from  forty  to  sixty  minutes,  or  in 
seventy -five  minutes  at  the  latest.  If  it  is  deferred  still  longer,  motor 
insufficiency  is  indicated.  The  sign  is  of  value  only  when  the  ex- 
cretion is  delayed.  Urine  containing  salicylic  acid  gives  a  dark, 
brownish-red  color  upon  the  addition  of  a  drop  of  tincture  of  the 
ohloride  of  iron. 

Klemperer's  oil-test  is  more  accurate,  although  disagreeable.  One 
hundred  grammes  of  oil  are  placed  in  the  stomach  by  the  stomach-tube. 
In  two  hours  the  stomach-contents  are  removed  by  aspirating,  previously 
adding  a  little  water.  The  amount  of  oil  is  dissolved  by  ether,  the 
solution  evaporated,  and  the  residuum  of  oil  weighed.  Seventy-five  to 
eighty  per  cent,  of  the  oil  should  be  discharged  in  two  hours. 

V.  The  Absorptive  Power.  .  Penzoldt  and  Faber  recommend 
the  administration  of  three  grains  of  chemically  pure  iodide  of  potas- 
sium— i.  e.,  free  from  iodic  acid — a  short  time  before  dinner.  Any 
fragments  of  free  iodine  adhering  to  the  iodide  of  potash  are  first 
carefully  washed  away.  The  saliva  is  tested  for  iodine  with  starch- 
paper  and  fuming  nitric  acid.  If  absorption  is  active,  a  violet  color 
is  obtained  in  from  six  and  one-half  to  eleven  minutes,  and  a  blue 
color  in  from  seven  and  one-half  to  fiiteen  minutes.  Zweifel  directs 
that  3  grains  (2  grammes)  of  iodide  of  potassium  be  administered  in 
a  gelatine  capsule,  and  Sh  oz.of  water  (100  c.c.)  taken;  iodine  is  detected 
in  about  eight  minutes  in  the  saliva.  The  character  of  the  food  taken 
IS  said  to  have  considerable  influence  in  retarding  the  appearance  of  the 
reaction,  so  that  the  blue  reaction  may  not  appear  for  forty-five  minutes. 
Boas  states  that  in  dilatation  of  the  stomach  the  reaction  may  be  de- 
layed to  two  hours,  and  in  cancer  as  long  as  eighty-two   minutes. 


526  SPECIAL  DIAGNOSIS. 

Both  motor  and  absorptive  power  are  recognized  also  by  digestive 
delay. 

Clinical  Value  of  a  Chemical  Examination  of  the  Vomitus  or  Stomach- 
contents.  It  cannot  be  gainsaid  that  the  chemical  examination  of  the 
stomach-contents  is  of  the  utmost  clinical  value.  It  is  just  as  certain, 
however,  that  the  results  attained  by  such  examination  should  not  be 
final  in  the  formation  of  a  diagnosis  ;  that  alone  they  do  not  meet  the 
expectations  of  clinicians.  This  is  particularly  so  when  we  attempt 
to  deduce  a  scientific  therapeusis  from  such  examination.  To  rely  upon 
the  results  of  such  examination  alone  would  lead  to  failure.  The 
diagnosis,  and,  therefore,  the  rational  therapeusis,  must  rest  not  upon 
a  chemical  examination,  but  also  upon  other  methods  of  examination 
of  stomach-contents,  the  physical  examination  of  the  stomach,  the 
history  and  progress  of  the  case,  and  the  subjective  symptoms.  In 
short,  a  general  view  must  be  taken,  and  all  methods  of  inquiry  em- 
ployed. 

Diseases  of  the  stomach  require  for  their  correct  estimation  broader 
lines  of  investigation  than  almost  any  other  organ  of  the  body.  More- 
over, the  practitioner  must  not  be  discouraged  if  he  cannot  employ  chem- 
ical methods  with  the  skill  of  the  laboratory  expert.  The  simple 
methods  detailed  above  can  be  conducted  by  any  educated  physician. 
For  practical  purposes  it  is  only  necessary  to  determine  the  total  acid- 
ity, the  presence  of  free  acids,  the  presence  of  free  HC1,  the  presence 
of  lactic  acid  and  of  the  volatile  acids. 

Finally,  the  clinician  must  not  be  discouraged  if  the  stomach-contents 
cannot  be  secured  on  account  of  the  contraindications  previously  de- 
tailed. As  accurate  a  diagnosis — probably  not  so  precise  or  final — can 
be  made  by  means  of  a  physical  examination  of  the  stomach. 

•  The  results  of  the  chemical  examination  have  the  clinical  value 
estimated  herewith.  In  the  first  place,  we  find  whether  the  acidity  is 
increased  or  diminished. 

1.  Diminished  acidity,  or  anacidity,  means  deficiency  in  the  amount 
of  HC1  secreted.  Diminished  acidity  may  be  due  to  functional  or 
organic  disease  of  the  stomach.  It  occurs  in  fever,  in  chlorosis,  and 
pernicious  anaemia,  chronic  wasting  diseases,  including  tuberculosis, 
and  acute  infectious  diseases  from  functional  disturbance  of  nervous 
or  hsemic  origin.  It  occurs  in  chronic  dyspepsia  from  irregularities 
in  diet.  It  is  also  deficient  in  congestion,  acute  catarrh  or  atrophy 
of  the  mucous  membranes,  and  in  carcinoma,  which  apparently 
modifies  gastric  secretion. 

2.  Increased  acidity  may  be  due  to  an  increase  of  hydrochloric  acid 
— hyperacidity,  or  to  an  increase  of  the  organic  acids — increased 
acidity,  a.  Hypersecretion  of  HC1  takes  place  in  the  early  stages  of 
gastric  irritation — dyspepsia.  It  may  be  increased  in  gastric  ulcer. 
6.  Increased  acidity  (organic  acids)  may  be  due  to  excess  of  (1)  lactic 
acid ;  (2)  of  butyric  acid,  and  (3)  of  acetic  acid.  Excess  of  lactic  acid 
is  due  to  fermentation  of  carbohydrates  from  the  growth  of  the  bacillus 
acidi  lactici  or  bacillus  lactis  aerogenes;  of  butyric  acid,  to  butyric  acid 
fermentation;  of  acetic  acid,  to  alcoholic  fermentation  of  the  above- 
mentioned  class  of  foods.     Alcoholic  fermentation  is  due  often  to  the 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     527 

sarcinse.  In  short,  they  are  the  result  of  bacterial  fermentation,  a  pro- 
cess which  takes  place  only  when  there  is  delayed  motor  power,  or  when 
the  normal  antiseptic — the  HC1 — is  absent  or  diminished.  Hence  we 
find  these  acids  in  weakness  of  the  muscle,  as  in  dilatation,  in  organic 
obstruction  of  the  pylorus,  and  in  cancer  of  the  stomach;  while  the 
bacteria  are  found  on  microscopical  examination. 

3.  Free  hydrochloric  acid  is  diminished  in  acute  and  chronic  catarrh  of 
the  stomach  (gastritis),  in  chronic  dyspepsia,  in  ulcer  of  the  stomach  and 
duodenum,  in  gastric  atrophy,  in  dilatation,  iu  gastric  carcinoma  (early 
stage),  and  from  all  general  causes  which  lessen  the  total  acidity,  includ- 
ing diabetes  and  Addison's  disease.  Of  course, deficiency  of  hydrochloric 
acid  means  deficiency  of  functional  activity,  and  goes  hand-in-hand 
with  diminished  motor  and  absorptive  power.  The  acid  is  increased 
in  the  early  stages  of  irritative  dyspepsia  and  in  ulcer  of  the  stomach, 
and  at  different  periods  in  the  gastric  neuroses.  The  most  common 
causes  of  increase  of  HC1  are  the  gastric  neuroses.  Hydrochloric  acid 
is  absent  entirely  in  advanced  chronic  gastritis  and  in  the  gastric  neu- 
roses. In  the  former  there  are  evidences  of  fermentation.  HC1  is 
often  absent  in  cancer,  but  unless  constantly  absent,  and  two  or  more 
other  facts  of  value  can  be  secured,  the  diagnosis  cannot  be  made  on 
the  chemical  examination  alone. 

4.  Lactic  acid.  Its  presence  points  to  fermentation,  hence  it  is  asso- 
ciated with  lesions  with  which  bacterial  fermentation  is  in  progress. 

It  is  present  in  carcinoma,  as  pointed  out  by  Boas.  Fermentation 
is  not  the  only  condition  favorable.  It  is  nearly  always  found  after 
a  meal  of  meat,  and  is  known  as  sarcolactic  acid.  It  may  occur  in 
chronic  catarrhal  gastritis.  In  cancer  of  the  stomach  lactic  acid  is  the 
most  common  objective  sign.  Its  absence  does  not  exclude  carcinoma. 
It  may  be  detected  before  a  tumor  is  palpable.  Therefore,  if  lactic 
acid  is  present  and  free  HC1  absent,  cancer  can  be  pretty  safely  diag- 
nosticated, particularly  if  stagnation  of  stomach-contents  is  also  present. 
Boas  recommends  a  meal  which  will  not  yield  sarcolactic  acid.  It 
is  one  to  two  litres  of  oatmeal  gruel,  to  which  a  little  salt  may  be 
added.  It  should  be  removed  by  expression  one  hour  after  it  has 
been  taken. 

The  clinical  value  of  the  remaining  chemical  tests  and  investigations 
need  not  be  explained.  They  indicate  inability  of  the  gastric  func- 
tion to  accomplish  digestion,  but  do  not  point  to  any  special  gastric 
affection.  They  are  of  value  in  distinguishing  between  gastric  neu- 
roses and  an  organic  disease.  In  both  there  are  pronounced  gastric 
symptoms  :  if  the  examination  shows  normal  digestive  powers,  a 
neurosis  is  indicated. 

Gastric  Hemorrhage.  Hemorrhage  of  the  stomach,  hcematemc- 
sis,  or  vomiting  of  blood,  is  due  to  an  organic  lesion,  or  the  effects  of 
acute  irritant  poisoning.  The  Wood  is  vomited.  Care  must  be  taken 
to  see  that  the  blood  is  not  from  the  upper  air-passages,  and  previously 
swallowed.  If  hemorrhage  is  profuse,  the  blood  may  cause  irritation 
of  the  larynx,  and  provoke  paroxysms  of  coughing.  It  is  often  diffi- 
cult, therefore,  to  distinguish  between  hemorrhage  from  the  lungs  and 
hemorrhage  from  the  stomach. 


528  SPECIAL  DIAGNOSIS. 


H^MATEMESIS. 

1.  Previous  history  points  to  gastric,  hepatic, 
or  splenic  disease. 

2.  The  blood  is  brought  up  by  vomiting,  prior 
to  which  the  patient  may  experience  a  feeling 
of  giddiness  or  faintness." 

3.  The  blood  is  usually  clotted,  mixed  with 


HEMOPTYSIS. 


1.  Cough  or  signs  of  some  pulmonary  or  car- 
diac disease  precedes,  in  many  cases,  the  hemor- 


2.  The  blood  is  coughed  up,  and  is  usually 
preceded  by  a  sensation  of  tickling  in  the  throat. 
If  vomiting  occurs,  it  follows  the  coughing. 

3.  The  blood  is  frothy,  bright  red  in  color, 


particles  of  food,  and  has  an  acid  reaction.    It  \  alkaline  in  reaction.     If  clotted,  is  rarely 
may  be  dark,  grumous,  and  fluid.  such  large  coagula,  and  muco-pus  may  be  mixed 


4.  Subsequent  to  the  attack  the  patient  passes 
tarry  stools,  and  signs  of  disease  of  the  abdomi- 
nal Viscera  may  be  detected. 


with  it. 

4.  The  cough  persists,  physical  signs  of  local 
disease  in  the  chest  may  usually  be  detected, 
and  the  sputa  may  be  blood-stained  for  many 
days.  (Osler.) 


The  hemorrhage  may  continue  within  the  stomach  without  exciting 
vomiting.  The  general  symptoms  of  hemorrhage  may  appear  first, 
as  pallor,  dimness  of  vision,  giddiness  or  faintness.  The  blood  which 
comes  from  the  stomach  is  usually  acted  upon  by  the  gastric  juice,  and 
is  dark,  clotted,  and  partly  digested.  It  is  often  mixed  with  food.  It 
is  acid  in  reaction.  In  large  hemorrhages  the  blood  may  be  fluid  and 
of  a  scarlet  color;  but  if  retained  for  any  length  of  time,  it  is  coagu- 
lated. The  vomited  matter  has  the  appearance  of  coffee-grounds, 
when  there  is  a  small  amount  of  blood.  When  large  in  amount  and 
digested  it  appears  like  tar. 

Vomiting  is  usually  followed  by  movements  of  the  bowels.  The 
matter  discharged  is  of  characteristic  appearance.  It  is  black  or  tarry. 
It  is  distinguished  from  hemorrhage  of  the  intestinal  canal  below  the 
duodenum  by  the  color  of  the  blood.  In  intestinal  hemorrhage  from 
this  situation  the  blood  is  distinctly  red.  The  dark  stools  must  not 
be  confounded  with  the  same  character  of  stools  seen  when  iron  or 
bismuth  is  taken.  In  rare  instances  a  hemorrhage  of  the  stomach  may 
take  place  because  of  disease  of  the  lower  part  of  the  oesophagus. 

Causes.  1.  General  diseases,  from  changes  in  the  blood,  cause  gas- 
tric hemorrhage,  as  scurvy,  purpura,  hemorrhagic  smallpox,  yellow 
fever,  acute  yellow  atrophy  of  the  liver,  and  severe  anaemia,  leukaemia, 
Hodgkiu's  disease,  and  pernicious  anaemia.  2.  Ulcer  of  the  stomach. 
3.  Cancer  of  the  stomach.  4.  Ulcer  of  the  duodenum.  5.  Portal 
congestion,  as  in  cirrhosis  of  the  liver,  and  other  forms  of  chronic 
hepatic  disease.  6.  Disease  of  the  spleen.  7.  Congestion  due  to 
disease  of  the  heart.  8.  In  chronic  Bright' s  disease  with  atheroma. 
9.  Rupture  in  aneurism.  10.  Vicarious  menstruation.  11.  Cohen 
asserts  that  it  occurs  in  vasomotor  ataxia. 

Profuse  and  sudden  hemorrhage,  in  the  absence  of  well-marked 
symptoms  of  disease,  is  in  nearly  all  cases  due,  either  to  latent  ulcer, 
or  to  congestion  of  the  stomach  from  early  cirrhosis  of  the  liver. 


Data  Obtained  by  Inquiry.      The' Subjective  Symptoms  of 
Diseases  of  the  Stomach. 

The  following  subjective  symptoms  may  be  complained  of  :  Dis- 
order of  appetite,  bad  taste  in  the  mouth,  thirst,  eructations,  pyrosis, 
distress  or  weight  after  meals,  burning  after  meals,  flatulency,  nausea, 
vomiting,  constipation,  diarrhoea,  pain,  vertigo,  and  cardiac  palpitation. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     529 

Nearly  all  the  subjective  symptoms  are  gastric  neuroses,  and  will  be 
detailed  in  the  chapter  devoted  to  the  neuroses. 

Bad  Taste.  It  is  usually  due  to  acute  catarrh.  It  may  be  present 
in  chronic  catarrh.  It  is  said  to  be  characteristic  of  the  acute  form 
of  gastritis  popularly  known  as  biliousness. 

Thirst.  Thirst  is  not  a  symptom  of  gastric  disorder  alone  ;  it  is  a 
symptom  of  diabetes  and  all  conditions  in  which  the  body  has  lost  fluids, 
as  water  by  sweating,  vomiting,  or  purging,  blood  by  hemorrhage,  or 
water  by  evaporation  and  combustion  (fever).  It  is  common  in  acute 
and  chronic  gastritis,  particularly  in  the  alcoholic  form. 

Distress,  Weight,  and  Burning.  They  are  frequent  complaints, 
and  may  come  on  immediately  after  meals.  They  may  be  due  to  dys- 
pepsia, hyperacidity,  dilatation,  bacterial  fermentation,  and  flatulency. 
They  exist  in  varying  degrees,  either  singly  or  combined  (see  Gastric 
Hy  persesthesi  a) . 

Nausea.  This  symptom  is  usually  associated  with  vomiting.  In 
some  persons  it  is  impossible  to  excite  vomiting,  although  they  may 
suffer  intolerably  from  nausea.  Nausea  is  akin  to  vomiting  in  its 
mechanism  and  clinical  associations  (q.  v.).  It  is  a  common  incident 
in  chronic  interstitial  nephritis.  In  old  people,  with  arterial  sclerosis 
and  defective  renal  elimination,  it  is  common.  It  may  be  due  to  irri- 
tating ingesta,  to  hyperacidity,  to  gastrectasia,  or  to  toxins  formed 
within  the  stomach. 

Vomiting.  Vomiting  takes  place  when  the  stomach  is  compressed 
by  the  abdominal  muscles  and  diaphragm,  coincidently  with  relaxation 
of  the  so-called  cardiac  sphincter  of  the  oesophagus.  Sometimes  there 
are  nausea  and  violent  efforts  at  expulsion  on  the  part  of  the  stom- 
ach, but  no  vomiting  occurs  because  the  cardiac  orifice  of  the  stomach 
is  not  at  the  same  time  opened.  Again,  there  may  be  profound  relax- 
ation of  the  oesophagus,  but  no  compression  of  the  stomach  by  the 
diaphragm  and  abdominal  muscles.  Both  factors  must  operate  at  the 
same  time  to  result  in  vomiting.  This  explains  why  it  is  that  some 
persons  suffer  extreme  nausea  and  have  even  violent  retching,  but  are 
unable  to  vomit. 

It  is  to  modern  physiologists — Schiff  and  Budge  and  Brunton — that 
we  owe  a  correct  explanation  of  the  physiology  of  vomiting. 

From  them  we  learn  that  there  is  a  neryous  centre  for  vomiting, 
which  is  seated  in  the  medulla  oblongata,  in  close  proximity  to  and 
intimately  connected  with  the  respiratory  centre.  It  is  to  this  centre 
that  impressions  are  sent  from  the  brain  itself  or  from  various  portions 
of  the  body  by  their  nerve-supply,  and  from  this  centre  motor  impulses 
are  transmitted  to  the  muscles  concerned  in  the  act  of  vomiting,  and 
to  the  stomach  and  oesophagus.  In  his  usually  graphic  manner  Brun- 
ton has  described  the  entire  mechanism. 

By  a  very  good  diagram  (see  Fig.  104)  the  author  indicates  the  affer- 
ent nerves  which  transmit  impulses  to  the  vomiting-centre,  exciting 
it  to  action.  They  are  :  pharyngeal  branches  of  the  glosso-pharvn- 
geal  ;  pulmonary  branches  of  the  vagus  ;  gastric  branches  of  the 
vagus;  gastric  branches  of  the  splanchnic;  renal,  mesenteric,  uterine, 
ovarian,  and  vesical  nerves.      Fibres  pass  downward  from  the  brain, 

34 


530  SPECIAL  DIAGNOSIS. 

conducting  impressions  to  the  vomiting-centre  from  the  organs  of  spe- 
cial sense,  from  the  brain-substance  or  its  membranes  when  the  seat  of 
disease,  or  from  central  ganglia  excited  by  emotion  or  imagination. 

Fig.  104. 


nervous  centre 
j  of  vomiting  in 
i  the  medulla 
[oblongata 


LIVER    i 
GALL-BLAC 


stomach- 


kidney   I I 

VND    URETER  J         / 


INTESTINE""*--  f        /  /         I  \ 

\     11/     /  L V.  J  UTERINE 

\nzyy 'I  f>^(  \      I   NERVES 

UTERUS \""/5R\\*'     1  / 

BLADDER VSt    I    '    /  / 

VESICALl _/"■ ' 

NERVE    1    " 

The  nervous  mechanism  of  vomiting. 

From  this  it  is  seen  that  vomiting  is  a  reflex  act ;  that  its  mechanism 
is  quite  simple  ;  and  that  a  proper  understanding  of  this  mechanism 
is  essential  to  a  correct  appreciation  of  its  pathology  and  treatment. 
Reference  has  not  been  made  to  the  vomiting  that  occurs  in  the  initial 
stage  of  many  fevers,  and  in  septicaemia,  uraemia  and  allied  affections, 
and  to  the  vomiting  of  hysteria.  In  the  former  it  is  doubtless  due  to 
the  direct  action  of  the  poisoned  blood  on  the  centre,  but  it  can  also 
readily  be  seen  to  be  due  to  the  propagation  of  impulses  to  the  centre 
from  the  brain  that  is  irritated  by  the  blood.  If  the  phenomena  of 
hysteria  are  due  to  an  abeyance  of  the  processes  of  inhibition,  the 
occurrence  of  vomiting  can  be  said  to  arise  from  the  non-control,  by 
higher  centres,  of  this  centre.  (From  "  Vomiting,  Physiological  and 
Clinical."      Trans.  Penna.  State  Med.  Soc,  1887.     Musser.) 

The  significance  of  vomiting  in  a  given  case  can  sometimes  be  deter- 
mined very  readily,  and  sometimes  it  remains  in  doubt  after  very  care- 
ful examination  and  questioning  of  the  patient.  In  seeking  for  an 
explanation  of  vomiting  it  is  of  importance  to  find  out  the  previous 
health  of  the  patient ;  whether  it  occurred  after  the  patient  had  been 
ill  for  a  longer  or  shorter  time,  or  suddenly,  when  he  was  in  apparent 
health,  or  whether  it  formed  one  of  the  initial  symptoms  of  an  acute 
disease. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     531 

Again,  inquiry  should  be  made  as  to  the  supposed  cause  of  the  vom- 
iting ;  whether  it  was  excited  by  the  taking  of  food,  drink,  or  medi- 
cine, or  by  some  disgusting  sight  or  odor. 

Further,  the  time  of  the  occurrence  of  the  vomiting  should  be  ascer- 
tained, as  well  as  its  frequency,  and  Avhether  preceded  by  nausea,  pain 
(noting  its  locality),  injury,  coughing,  jaundice,  or  constipation. 

The  position  of  the  patient  at  the  time  the  vomiting  occurs  some- 
times furnishes  a  valuable  clue  to  its  cause. 

The  effect  of  the  vomiting  is  sometimes  of  aid  in  diagnosis.  In  ulcer 
and  migraine,  for  example,  it  affords  marked  relief. 

Finally,  the  appearance  and  quantity  of  the  matter  vomited  are  very 
important  (see  Objective  Signs). 

Character.  Vomiting  may  occur  occasionally,  persistently,  or 
periodically.  It  may  be  projectile  and  painless,  or  difficult  and 
painful.  The  former  is  characteristic  of  cerebral  disease  or  reflex 
vomiting  ;  the  latter  of  local  gastric  disease.  When  vomiting  occurs 
suddenly,  without  antecedent  illness,  it  usually  indicates  some  local 
affection  of  the  stomach,  or  is  due  to  some  nervous  impression,  or 
marks  the  onset  of  some  acute  general  disease. 

Vomiting  in  gastric  disease.  The  local  affections  of  the  stomach 
attended  by  vomiting  are  acute  and  chronic  gastritis  (especially  the 
catarrhal  form),  dyspepsia,  ulcer,  cancer,  and  dilatation. 

In  acute  gastritis  there  will  be  a  history  of  an  acute  illness  marked 
by  severe  local  and  general  symptoms.  The  cause  of  the  gastritis 
may  be  found  to  be  overeating  of  highly  seasoned  or  indigestible  food; 
abuse  of  alcohol,  narcotics,  or  sedatives;  drinking  water  to  which  the 
patient  is  unaccustomed  ;  poisoning  with  such  drugs  as  arsenic  and 
mercury  ;  sudden  changes  in  atmospheric  conditions  in  susceptible 
persons.  The  vomiting  is  preceded  by  nausea,  epigastric  pain  and 
tenderness,  and  often  followed  by  profound  prostration. 

The  vomited  matters  consist,  first,  of  the  contents  of  the  stomach 
(which  may  throw  light  on  the  cause  of  the  attack),  then  of  mucus, 
saliva  (which  has  been  swallowed),  bile,  and,  in  grave  cases,  altered 
blood. 

In  chronic  gastritis  vomiting  often  occurs  in  from  half  an  hour  to 
an  hour  and  a  half  after  eating,  the  food  being  only  partly  digested 
and  sometimes  coated  with  mucus.  It  does  not  produce  the  prostra- 
tion that  vomiting  in  acute  gastritis  does,  and  is  followed  by  some  relief 
to  the  gastric  uneasiness  and  pain.  The  emaciation  may  suggest  cancer 
of  the  stomach. 

In  ulcer  of  the  stomach  vomiting  is  rarely  absent.  It  occurs  usually 
soon  after  taking  food,  and  its  occurrence  affords  relief  to  the  gastric 
pain.  There  is  nothing  characteristic  in  the  vomit  unless  it  contains 
blood.  Welch  thinks  that  gastric  hemorrhage  in  recognizable  amount 
occurs  in  about  one-third  of  the  cases. 

In  cancer  of  the  stomach  vomiting  is  an  almost  constant  symptom, 
but  it  may  not  occur  until  comparatively  late  in  the  disease,  or,  more 
rarely,  may  be  one  of  the  earliest  symptoms.  Usually  it  does  not 
appear  until  dyspeptic  symptoms  have  persisted  for  some  time.  There 
is  no  uniformity  in  the  frequency  of  its  occurrence  or  in  the  character 


532  SPECIAL  DIAGNOSIS. 

of  the  vomit.  As  a  rule,  vomiting  occurs  at  a  longer  interval  after 
taking  food  than  in  the  case  of  ulcer,  and  the  ejection  of  food  does 
not  give  as  much  relief  to  the  patient.  Vomiting  may  occur  every 
clay  or  several  times  a  day  in  the  early  stages,  but  if  dilatation  of  the 
stomach  develops,  as  it  usually  does  in  cancer  of  the  pylorus,  vomiting 
may  be  deferred  for  several  days,  and  then  be  correspondingly  more 
copious  in  amount.  Blood,  frequently  altered  by  gastric  juice  so  as  to 
resemble  coffee-grounds,  is  a  common  constituent  of  the  vomit  (see 
under  Inspection).  Vomiting  frequently  marks  the  onset  of  acute 
diseases,  especially  pneumonia  and  the  eruptive  fevers  and  yellow  fever. 
Marked  vomiting  generally  indicates  that  the  case  will  be  severe. 

Reflex  vomiting.  Nausea  and  vomiting  are  excited  in  some  persons 
by  the  sight  of  blood,  or  by  a  horrible  or  loathsome  spectacle;  others 
are  more  susceptible  to  foul  odors  and  disgusting  tastes. 

Vomiting  is  frequently  reflex,  that  is  to  say,  irritation  at  some  point 
is  transmitted  by  the  proper  afferent  nerve  to  the  vomiting-centre  and 
then  reflected  to  the  stomach.  Vomiting  of  this  character  occurs  in 
pregnancy,  diseases  of  the  appendix  vermiformis,  ovaries,  uterus, 
bladder,  prostate  gland,  lungs,  nose,  eyes,  kidneys,  intestine,  peritoneum, 
liver,  gall-bladder,  and  bile-ducts. 

Vomiting  is  found  to  be  of  reflex  origin  when  there  is  no  local  affec- 
tion of  the  stomach  present,  and  no  general  disease  to  account  for  it, 
and  when  a  remote  source  of  irritation  can  be  discovered,  the  removal 
or  mitigation  of  which  checks  this  vomiting.  The  particular  organ 
which  is  the  source  of  the  irritation  must  be  determined  by  a  careful 
physical  examination  guided  by  the  indications  furnished  by  the  age, 
sex,  time  of  occurrence,  habits,  and  other  symptoms  which  accompany 
the  vomiting. 

The  nausea  and  vomiting  from  which  many  women  suffer  during 
the  early  months  of  pregnancy  are  most  marked  on  rising  in  the  morn- 
ing; they  are  aggravated  if  the  patient  has  been  on  her  feet  much  or 
has  been  subjected  to  any  exhausting  or  worrying  influence ;  on  the 
other  hand,  they  are  relieved  by  quiet  and  the  recumbent  posture. 
In  diseases  of  the  ovary,  uterus,  bladder,  and  prostate  there  are  local 
pain,  catarrhal  symptoms,  inflammation  or  enlargement  to  attract  atten- 
tion. 

The  lungs  are  probably  not  often  the  cause  of  reflex  vomiting. 
Rarely,  however,  phthisis  is  so  masked  by  gastric  symptoms  and  vomit- 
ing as  to  be  overlooked.  More  frequently  it  is  the  act  of  coughing 
and  the  effort  to  expel  the  sputa  from  the  throat  that  produce  the  vom- 
iting. Expectoration  tickles  the  throat  and  may  have  the  same  effect 
as  the  finger  or  feather  in  inducing  vomiting.  This  seems  to  be  the 
explanation  of  the  vomiting  which  follows  a  hard  spell  of  coughing 
in  pertussis. 

Peritonitis  may  be  suspected  to  be  the  cause  of  vomiting  if  there 
has  been  injury  to  the  peritoneum  from  a  surgical  operation,  or  if  it 
has  been  exposed  to  infection  through  the  uterus  and  tubes,  or  from 
disease  of  organs  surrounded  by  it,  as  the  vermiform  appendix.  Vom- 
iting may  be  the  only  symptom  present  except  collapse.  The  fluid  is 
not  only  ejected,  but  regurgitated,  and  may  appear  to  flow  from  the 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     :/.];) 

stomach.     Large  amounts  of  fluid  are  discharged,  clear  or  of  a  green 
color. 

In  the  vomiting  due  to  the  passage  of  a  renal  calculus  or  gallstone 
the  colicky  pains  and  their  location  definitely  point  to  the  source. 

Vomiting  in  toxaemias.  Vomiting  is  also  a  marked  symptom  of 
toxaemias ;  they  produce  vomiting  probably  by  direct  irritation  of  the 
vomiting-centre.  Among  such  diseases  are  the  specific  fevers,  notably 
scarlet  fever  and  yellow  fever ;  sewer-gas  poisoning ;  diseases  of  the 
liver  and  kidney,  which  produce  cholcemia  and  uraemia,  particularly 
cirrhosis  of  the  liver  and  interstitial  nephritis. 

The  vomiting  of  uraemia  usually  occurs  in  the  morning.  It  is  accom- 
panied  by  nausea  and  depression.  "Whenever  morniug  nausea  and  vom- 
iting occur  in  an  adult  without  obvious  local  cause  the  urine  should  he 
examined.  Other  confirmatory  signs  are  high-tension  pulse,  accentua- 
tion of  the  aortic  second  sound,  and  hypertrophy  of  the  heart. 

Cerebral  Vomiting.  Vomiting  due  to  cerebral  disease  is  well  recog- 
nized. In  early  life  it  is  a  characteristic  feature  of  meningitis  and 
tumor  of  the  brain.  It  is  likewise  of  moment  in  later  life.  I  am  of 
the  conviction,  however,  that  it  is  not  sufficiently  recognized  as  one  of 
the  first  symptoms  of  apoplexy.  True,  we  find  that  apoplexy  occurs 
after  a  full  meal,  when  the  attack  is  associated  with  indigestion,  with 
efforts  at  vomiting  ;  and  I  do  not  here  refer  to  such  cases,  but  to  cases 
of  painless,  often  watery  vomiting,  occurring  without  nausea  and  with- 
out retching.  A  sudden,  violent  expulsion  of  the  stomach  contents, 
ceaseless,  unrelieved  by  remedial  measures,  has  been  seen  by  the 
writer  to  precede  other  signs  of  apoplexy  by  from  thirty  minutes  to 
twenty-four  hours.  In  all  cases  of  an  apoplectic  character  the  pulse 
is  slow  and  full,  while  in  nausea  and  vomiting  from  other  causes,  in 
the  aged  particularly,  it  is  weak  and  feeble.  Moreover,  some  alter- 
ation of  breathing  is  noticed.  It  is  either  irregular,  or  slow,  or 
unduly  hurried.  It  proves  the  intimate  relation  of  the  vomiting  and 
the  respiratory  centres.  Further,  strength  is  seen,  not  weakness  ;  in 
the  apoplectics  the  face  is  congested,  not  pallid  as  in  simple  sick 
stomach.  The  other  peculiarities  of  cerebral  vomiting  have  been 
indicated. 

Crises.  Sudden  attacks  of  vomiting  with  hyperacidity,  with  or 
without  pain,  often  occur  in  locomotor  ataxia.  Such  attacks  occur  in 
other  affections,  as  hysteria.  They  occur  in  movable  kidney,  and  are 
known  as  Dietl's  crises. 

Diagnosis.  Vomiting  is  readily  recognized.  It  is  often  productive 
of  serious  symptoms.  It  may  cause  apoplexy  or  cerebral  congestion  ; 
it  may  cause  acute  overdistension  of  a  dilated  heart,  as  in  aortic  regur- 
gitation. If  it  continues  for  any  length  of  time,  and  much  fluid  is 
ejected,  it  is  attended  by  anuria,  and  rapidly  followed  by  collapse.  It 
also  i  i id  i  ices  thirst. 

Flatulency.  Flatulency  is  an  accumulation  of  gas  in  the  stomach 
or  intestines^  It  is  a  very  common  source  of  complaint  on  the  part  of 
patients.  Gastric  flatulency  is  marked  by  a  distention  of  the  stomach, 
with  the  discomfort  which  it  occasions,  and  by  the  eructation  of  gas 
at  variable  intervals  after  the  taking  of  food.      When  the  gas  is  the 


534  SPECIAL  DIAGNOSIS. 

result  of  the  fermentation  which  accompanies  the  production  of  the 
fatty  acids  flatulency  is  frequently  accompanied  by  pain,  which  is 
relieved  by  eructations.  When  the  distention  is  great  or  long  contin- 
ued, disturbances  in  the  action  of  the  heart,  particularly  palpitation 
and  intermittency,  are  likely  to  occur.  Occasionally  it  interferes  with 
the  breathing,  and,  from  the  apprehension  which  this  symptom  and 
palpitation  excite,  faintness  and  inaptitude  for  mental  and  physical 
work  may  arise. 

Flatulence  may  be  due  to  carbonic  acid,  which  is  generated  and 
retained  on  account  of  motor  deficiency.  Tt  is  seen  in  the  middle- 
aged  and  in  the  old.  Flatulence  may  be  due  to  swallowed  air  enter- 
ing with  the  food  or  the  swallowed  saliva.  Flatulence  may  also  be 
due  to  the  regurgitation  of  pancreatic  juice,  as  in  fixation  of  the 
stomach-wall  and  open  pylorus.  It  comes  on  four  or  five  hours  after 
eating,  and  is  caused  by  the  carbonates  of  the  pancreatic  juice  becom- 
ing decomposed,  setting  free  carbonic  acid.  Flatulence  from  bacte- 
rial fermentation  is  seen  in  dilatation  of  the  stomach,  and  is  usually 
continuous.  It  also  occurs  in  chronic  indigestion.  Flatulence  in  rare 
instances  is  due  to  the  change  of  gas  between  the  blood  and  the  con- 
tents of  the  stomach.      Normally  it  is  known  as  intestinal  respiration. 

Excessive  flatulency  is  a  common  manifestation  of  hysteria.  .  Such 
patients  may  complain  of  something  rising  into  the  throat  from  the 
stomach  and  smothering  them  (globus  hystericus).  There  may  also  be 
tympanites,  and  even  phantom  tumor.  It  may  be  necessary  to  anaes- 
thetize the  patient  completely  to  diagnosticate  the  latter  from  genuine 
tumor. 

Vertigo.  The  stomach  is  but  one  of  a  number  of  sources  of  ver- 
tigo. Some  patients  find  by  experience  that  certain  articles  of  food, 
such  as  oysters  or  lobsters,  have  to  be  avoided  because  they  produce 
vertigo,  although  digestion  is  good,  and  more  indigestible  articles  can 
be  taken  without  inducing  any  such  result. 

In  other  cases  acute  indigestion  from  overeating,  particularly  if  it 
result  in  the  development  of  an  acid  condition  of  the  stomach,  is  apt 
to  be  accompanied  by  vertigo  when  the  stomach  symptoms  are  most 
severe.  Usually  the  vertigo  is  associated  with  headache,  more  or  less 
intense  ;  it  is  relieved  by  lying  down  and  closing  the  eyes,  but  does  not 
wholly  disappear  until  all  the  symptoms  gradually  subside  after  free 
vomiting.  Some  persons  are  subject  to  so-called  "  blind"  headaches 
— headaches  accompanied  by  dimness  of  vision,  more  or  less  mental 
confusion,  and  uncertainty  of  gait,  possibly  with  staggering  and  often 
with  vertigo.  Such  headaches  appear  to  be  due  to  an  acid  condition  of 
the  stomach,  and  are  relieved  by  alkalies  or  vomiting. 

It  is  difficult  to  separate  the  vertigo  of  chronic  gastric  or  gastro- 
intestinal dyspepsia  from  that  of  litliBeniia  or  latent  gout.  Probably 
both  are  due,  not  to  any  local  irritation  transmitted  to  the  brain,  but  to 
the  circulation  in  the  blood  of  toxic  products  of  digestion,  which  act 
upon  the  brain.  The  vertigo  is  not  so  severe  as  in  acute  indigestion 
or  acute  dyspepsia,  but  is  constant.  In  some  patients  it  is  associated 
with  unconquerable  aversion  to  walking  alone  upon  the  street. 

Pain.     Cardialgia  is  a  form  of  discomfort  in  the  epigastrium  scarcely 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     535 

amounting  to  pain,  but  attended  by  heartburn  or  acidity.  Gastro- 
dynia  is  a  violent  pain  spoken  of  as  cramp  or  spasm  of  the  stomach. 
The  pain  is  transient.  Gastralgia  is  a  form  of  pain  with  features 
like  that  of  neuralgia,  occurring  when  the  stomach  is  empty  (see 
Gastric  Neuroses). 

Location.  Pain  in  the  epigastrium.  Pain  referred  to  the  stomach 
is  situated  in  the  upper  zone  of  the  abdomen,  below  the  ensiform 
cartilage,  between  the  ribs  of  the  two  sides,  usually  in  the  median 
line.  It  may  be  along  and  under  the  left  ribs.  Pain  in  this  situa- 
tion may  be  due  to  a  number  of  causes  :  1.  To  myalgia,  neuritis, 
or  neuralgia  of  the  intercostal  nerves,  which  terminate  in  this  situa- 
tion (see  Abdominal  Pain).  2.  Localized  peritonitis  or  perigastritis, 
which  may  be  secondary  to  or  caused  by  infection  or  injury  of  the 
peritoneum  from  disease  of  contiguous  organs.  3.  Affections  of  the 
pancreas  may  cause  pain  :  a.  Pancreatic  colic,  a  rare  condition  asso- 
ciated with  diarrhoea,  intestinal  dyspepsia,  and  salivation.  The  pain 
is  paroxysmal,  the  attacks  lasting  two  or  three  hours,  b.  Pain  due 
to  carcinoma  of  the  pancreas,  darting  or  lancinating  in  character, 
associated  usually  with  tumor,  jaundice,  and  emaciation,  c.  Pain 
due  to  pancreatic  hemorrhage.  It  is  sudden  and  extremely  severe, 
attended  by  collapse.  4.  Pain  in  this  situation  may  be  due  to  aneu- 
rism of  the  aorta  or  of  the  coeliac  axis.  It  is  constant,  of  a  boring 
character,  and  may  be  associated  with  shooting-pains  along  the  course 
of  the  lumbar  nerves.  The  physical  signs  of  aneurism  are  present. 
5.  Pain  in  this  region  may  be  due  to  hepatic  colic.  6.  It  may  be  due 
to  disease  of  the  vertebras.  We  should  look  for  the  sixth  or  seventh 
dorsal  vertebra  to  be  affected,  hence  higher  up  posteriorly  than  the  area 
affected  in  front  would  indicate.  Finally,  7.  Affections  of  the  stom- 
ach. Of  these  we  have  :  a.  Gastralgia  in  all  its  forms  (see  Gastric 
Neuroses),  b.  Acute  and  chronic  gastritis,  c.  Gastric  ulcer,  d.  Car- 
cinoma of  the  stomach.  To  the  first  class  belongs  a  peculiar  pain 
which  occurs  in  locomotor  ataxia,  and  which,  on  account  of  its  sudden 
onset,  with  alarming  vomiting,  and  of  its  frequent  repetition,  is  known 
as  a  gastric  crisis. 

Pain  in  the  left  hypochondrium.  It  may  be  due  to  a  dilated  stomach 
or  distended  colon  (see  p.  47). 

Pain  of  gastric  origin.  In  diseases  of  the  stomach  pain  is  a  very 
common  symptom.  It  is  of  all  degrees,  from  a  mere  sense  of  discom- 
fort or  uneasiness  to  agony.  In  atonic  dyspepsia  there  may  be  no 
local  gastric  symptoms  except  a  feeling  of  weight  and  fulness,  while 
in  nervous  dyspepsia  there  is  usually  uneasiness  or  discomfort  after 
eating.  In  gastralgia  the  pain  is  characteristic  :  it  usually  conies  on 
while  the  stomach  is  empty,  and  frequently  recurs  daily  at  the  same 
hour.  At  first  the  pain  is  slight  and  easily  borne,  but  it  gradually 
increases  in  severity.  Each  succeeding  paroxysm  is  worse  than  the 
preceding  one,  until  a  climax  of  agony  is  reached.  In  character  the 
pain  is  gnawing  and  cramp-like,  doubling  the  patient  up,  and  after 
subsiding  leaving  him  moist  with  cold  sweat  and  in  partial  collapse. 

In  catarrhal  dyspepsia  there  are  pain  and  uneasiness  in  the  stomach 
after   eating,    with   tenderness  on   pressure.      If   flatulence  coexists, 


536  SPECIAL  DIAGNOSIS. 

there  will  be  temporary  relief  to  the  discomfort  upon  the  eructation 
of  gas. 

In  ulcer  there  is  a  more  or  less  constant  feeling  of  soreness  in  the 
epigastrium.  After  the  taking  of  food  the  dull  pain  is  aggravated  and 
becomes  sharply  localized.  Frequently  there  is  pain  in  the  back  at  the 
same  point,  a  little  to  the  left  of  the  spine  and  between  the  midscap- 
ular  region  and  the  lumbar  vertebras.  The  pain  usually  occurs  sooner 
after  taking  food  than  in  the  case  of  cancer,  and  is  more  frequently 
relieved  by  vomiting.  Attacks  of  gastralgia  are  not  rare,  and  the  pain 
may  shoot  down  the  arm. 

In  gastric  cancer  pain  may  be  wholly  absent  throughout  the  entire 
course  of  the  disease;  but,  as  a  rule,  pain  is  more  continuous  than  in 
ulcer,  less  severe,  not  so  sharply  localized,  does  not  come  on  so  soon 
after  taking  food,  and  is  not  relieved  to  the  same  degree  by  vomiting. 
Paroxysms  of  gastralgia  are  not  so  common. 

In  acute  gastritis  the  pain  and  its  character  vary  with  the  intensity 
of  the  inflammation.  If  due  to  the  irritation  of  some  toxic  agent 
which  has  been  swallowed,  the  pain  is  severe  and  burning ;  if  the 
result  of  imprudence  in  eating  and  drinking,  the  pain  is  of  a  dull, 
sickening  character.  In  either  case  there  is  more  or  less  tenderness  on 
pressure.  Sometimes,  in  mild  cases  of  catarrhal  gastritis,  firm  pressure 
from  a  broad  surface  affords  at  least  temporary  relief  to  the  distress. 

Time  of  pain.  The  significance  of  pain  depends  on  the  time  of  its 
occurrence.  Pain  coming  on  before  eating  or  when  the  stomach  is 
empty  is  due  to  gastralgia.  It  is  relieved  by  food.  When  it  comes 
on  after  eating  it  is  usually  due  to  organic  disease  of  the  stomach, 
as  ulcer  or  carcinoma  ;  but  it  may  be  due  to  neurasthenia.  It  must 
not  be  confounded  with  the  pain  that  occurs  from  two  to  four  hours 
after  meals,  caused  by  intestinal  indigestion  or  some  pancreatic  affec- 
tion. When  the  pain  is  diffused,  it  is  due  to  hyperacidity  and  bac- 
terial fermentation,  as  in  dilatation,  catarrhal  gastritis,  and  simple 
indigestion.  When  localized,  it  is  due  to  ulcer  or  cancer  and  is  asso- 
ciated with  tenderness.     It  may  extend  to  the  back. 

Alterations  of  Appetite.  Loss  of  appetite  or  anorexia  may 
be  due  to  a  number  of  diseases.  It  is  present  in  all  forms  of  organic 
disease  of  the  stomach  except  ulcer.  In  the  majority  of  cases  of 
this  affection  it  is  present.  It  may  or  may  not  be  present  in  gas- 
tric neuroses.  Everyone  is  familiar  with  the  loss  of  appetite  due 
to  nervous  impressions,  as  emotions,  anxiety,  or  mental  care.  It  is  of 
frequent  occurrence  in  disorders  remote  from  the  stomach,  Avhich  modify 
the  condition  of  the  organ  reflexly.  In  the  section  on  Vomiting  will 
be  found  statements  showing  the  influence  of  central  disease  and  disease 
of  distant  organs  upon  the  stomach  in  this  respect.  Through  the  same 
channels  and  through  the  same  mechanism,  and  hence  by  the  same 
group  of  causes,  loss  of  appetite  may  be  produced.  Loss  of  appetite 
is  a  constant  accompaniment  of  the  moderate  gastritis  which  attends 
all  fevers.  Reference  cannot  well  be  made  to  all  the  conditions  which 
induce  this  symptom.  In  all  forms  of  ansemia,  in  all  chronic  wast- 
ing diseases,  and  in  functional  and  organic  disease  of  the  nervous 
system  the  appetite  is  lost.     The  writer  has  been  particularly  impressed 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     537 

with  the  importance  of  determining  the  presence  or  absence  of  suppu- 
ration in  some  portion  of  the  body,  in  all  cases  in  which  there  is  loss 
of  appetite  or  disgust  for  food. 

Boulimia,  or  excessive  appetite,  sometimes  occurs.  It  is  popularly 
thought  to  be  due  to  worms  in  children.  It  is  a  common  symptom  in 
the  early  periods  of  diabetes,  and  is  said  to  be  present  in  disease  of 
the  mesenteric  glands.  It  occurs  also  in  gastric  neuroses.  Perversion 
of  the  appetite,  iu  which  all  sorts  of  substances  are  greedily  swallowed, 
occurs  in  hysteria,  dementia,  and  pregnancy.     It  is  known  as  pica. 

Regurgitation  of  gases  or  food  matter  is  a  frequent  symptom  of 
gastric  disorder.  It  is  also  known  as  belching  or  eructation.  It  may 
be  limited  to  the  discharge  of  gas,  although  sometimes  imperfectly 
digested  food  also  regurgitates  (see  Rumination). 

Regurgitation  of  the  gastric  juice  alone  causes  an  unpleasant  taste, 
and  the  fluid  is  hot  and  acrid.  The  juice  is  usually  brought  up  in  the 
belching  of  gas. 

Pyrosis,  or  water-brash,  is  a  common  symptom  in  some  forms  of 
dyspepsia.  It  may  occur  in  the  morning  when  the  stomach  is  empty, 
at  which  time  large  amounts  of  fluid  are  ejected.  The  fluid  is  thin  and 
watery,  sometimes  acid,  sometimes  tasteless.  In  other  cases  the  fluid 
is  slightly  alkaline.  The  fluid  is  ejected  without  vomiting.  Sometimes 
the  discharge  begins  immediately  after  eating.  The  late  Dr.  Chambers 
thought  that  the  fluid  was  saliva  which  was  swallowed,  and  retained 
in  the  lower  part  of  the  oesophagus  by  a  spasm  of  the  cardiac  orifice. 
When  a  sufficient  amount  is  collected  it  gushes  back  into  the  mouth. 
Pavy  and  Handheld  Jones  believe  that  the  fluid  is  secreted  by  the 
stomach,  while,  on  the  other  hand,  Roberts,  who  found  the  liquid  to 
possess  diastatic  power,  believes  it  to  be  due  to  saliva.  Acid  eructations 
from  hyperacidity  or  fermentation  occur  one  or  two  hours  after 
meals.  They  rarely  occur  in  dilatation,  but  are  common  in  over- 
feeding. 

Palpitation.  Increased  action  of  the  heart  is  a  common  symp- 
tom of  indigestion  due  to  flatulency  or  an  overloaded  stomach.  It 
occurs  in  the  middle  period  of  life,  in  the  anaemic  and  neurotic,  in 
cardiac  disease,  and  in  those  who  use  tea  and  tobacco  to  excess. 

Cough.  Cough  is  a  frequent,  symptom  of  gastric  disorder.  It 
may  be  due  to  the  pharyngitis,  which  has  been  set  up  by  acid  eructa- 
tions ;  it  may  be  mechanical,  when  a  distended  stomach  presses  upon 
the  diaphragm,  or  it  may  be  reflex.  Cough  after  meals  in  patients 
with  tuberculosis  or  other  pulmonary  affection  is  usually  due  to  pres- 
sure upon  the  diaphragm. 

Dyspncea.  This  occurs  in  many  cases  of  dyspepsia  if  the  subject 
is  the  victim  of  asthma,  is  anaemic,  or  subject  to  cardiac  disease. 
In  asthma  it  is  usually  reflex  ;  in  anaemia  it  is  due  to  the  attraction 
of  blood  to  the  stomach  in  normal  digestion;  in  cardiac  disease  it  is 
due  to  the  latter  or  it  is  mechanical. 

Hiccough,  or  singultus,  is  a  spasm  of  the  diaphragm.  The  con- 
tractions take  place  at  more  or  less  regular  intervals,  attended  with  a 
peculiar  clicking  sound.  This  sound  is  due  to  the  sudden  passage  of 
air  through  the  glottis.    Hiccough  may  be  a  serious  symptom.     It  may 


538  SPECIAL  DIAGNOSIS. 

last  but  a  few  minutes  or  continue  for  several  days.  In  the  latter  case 
it  causes  extreme  exhaustion.  Its  occurrence  in  chronic  disease  is  of 
bad  prognostic  omen. 

Drowsiness  is  frequently  seen  in  dyspeptics  after  meals.  Sleep- 
lessness is  of  frequent  occurrence.  It  may  be  due  to  the  irritation  of 
food  remaining  in  the  stomach  over  night  or  to  the  absorption  of 
toxic  products. 

Constipation.  This  symptom  will  be  discussed  in  the  chapter  on 
Intestinal  Diseases.  It  is  present  with  gastric  dilatation.  In  pyloric 
stenosis  it  is  always  present. 

Diarrhoea.  The  digestion  is  impaired  and  peristalsis  is  in  excess. 
Dienteric  diarrhoea  is  an  accompaniment  of  a  gastric  motor  neurosis. 
In  gastrectasia  the  fermentative  products  set  up  gastro-intestinal  catarrh 
which  induces  diarrhoea. 

Acute  Gastritis. 

The  simple  variety  of  acute  gastritis  varies  according  to  the  cause, 
from  a  slight  attack  of  vomiting  after  indiscretion  in  diet,  with  ordi- 
nary symptoms  of  indigestion,  to  the  more  severe  forms  ushered  in  by 
chill  and  attended  with  fever. 

In  the  mild  forms  there  is  a  sense  of  fulness  and  discomfort  in  the 
epigastrium,  attended  with  nausea.  The  appetite  is  lost  and  there  may 
be  disgust  for  food,  and  the  flow  of  saliva  is  increased.  There  is 
undue  acidity.  On  examination  the  epigastrium  is  found  to  be  tender. 
The  onset  of  the  attack  is  attended  with  giddiness,  flashes  of  light 
before  the  eyes,  frontal  headache,  and  some  prostration.  The  pulse  is 
increased  in  frequency.  When  this  nausea  is  most  pronounced  the 
face  is  pale  and  the  extremities  cold.  Vomiting  then  occurs,  the 
matter  rejected  consisting  of  ingesta  only  slightly  changed,  with  mucus 
and  watery  fluid.  It  is  very  bitter.  It  is  often  colored  green  from 
bile-pigment.  Another  attack  of  vomiting  may  be  sufficient  to  give 
relief,  or  it  may  be  repeated  for  twenty -four  to  forty-eight  hours  every 
hour  or  two.  After  the  stomach  is  relieved  of  food,  mucus  and  bile 
alone  are  vomited. 

Examination  of  Stomach-contents.  The  reaction  of  the  vomited 
matter  is  neutral  or  faintly  acid.  No  free  hydrochloric  acid  is  present, 
but  later  lactic  and  fatty  acids  are  found.  Pepsin  is  diminished  in 
quantity. 

Twelve  to  twenty-four  hours  after  the  gastric  symptoms  the  intes- 
tinal symptoms  may  arise.  Borborygmi  and  colicky  pains  are  com- 
plained of,  followed  by  diarrhoea  with  some  tenesmus. 

Herpes  labialis  may  occur,  and  some  writers  speak  of  a  peculiar 
odor  which  is  exhaled  from  the  skin." '  The  more  severe  cases  are  ush- 
ered in  with  chill  followed  by  fever.  The  local  symptoms  are  much 
aggravated.  The  tongue  is  furred,  the  breath  is  foul.  The  vomiting 
is  frequent  and  severe.  The  skin  is  livid  and  the  pulse  becomes  rapid. 
In  the  acute  cases  attended  by  fever  it  may  be  mistaken  for  meningitis, 
peritonitis,  or  hepatitis.  The  same  gastric  symptoms  may  usher  in  an 
attack  of  pneumonia.      The  possibilities  of  a  mistake  are  to  be  borne 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     539 

in  mind,  and  in  all  cases  of  vomiting  with  fever  due  regard  must  be 
paid  to  the  possibility  of  the  gastric  symptoms  being  symptomatic  only. 
It  must  be  borne  in  mind  that  the  same  group  of  symptoms  that  belong 
to  gastritis  accompany  the  exanthematous  diseases,  and  diphtheria, 
dysentery,  pyaemia,  and  puerperal  fever.  They  may  be  of  reflex  origin, 
or  due  to  the  action  of  fever,  poison,  or  ptomaines  on  the  stomach. 
Ewald  calls  it  sympathetic  gastritis  when  the  symptoms  are  the  same 
as  in  the  simple  variety,  masked,  however,  by  the  primary  disease. 
Sometimes,  however,  as  in  the  eruptive  fevers,  attention  is  directed  to 
the  state  of  the  stomach  to  the  exclusion  of  other  conditions.  And 
often,  to  the  surprise  of  the  student,  an  eruption  or  inflammation  ensues, 
which  indicates  the  true  nature  of  the  case. 

In  cases  of  gastritis,  therefore,  endeavor  to  find  a  local  cause  for  the 
symptoms.  If  there  is  no  history  of  indiscretion  in  diet,  of  exposure, 
of  exhaustion,  or  mental  shock,  on  account  of  which  digestion  might 
be  arrested,  then  inquire  for  a  history  of  exposure  to  contagious  dis- 
eases and  look  for  the  earlier  evidences  of  exanthemata.  If  the  result 
of  the  examination  is  still  unsatisfactory,  examine  the  condition  of 
each  individual  organ,  particularly  bearing  in  mind  meningitis,  pneu- 
monia, peritonitis,  and  nephritis. 

Phlegmonous  gastritis  is  a  very  rare  affection,  in  which  the  inflam- 
mation is  seated  in  the  submucosa  and  leads  to  perforation.  The  onset 
is  sudden.  The  chief  local  symptom  is  intense  pain  in  the  epigastrium, 
with  a  burning  sensation.  There  are  great  acidity,  dry  tongue,  and 
absolute  anorexia.  The  fever  is  high  and  characterized  by  delirium. 
Chills  usually  accompany  it.  The  pulse  is  small,  rapid,  and  irregular. 
The  matters  vomited  are  first  mucus,  then  pus.  The  patient  is  ex- 
tremely restless  and  anxious,  even  delirious,  and  early  passes  into  coma. 
Death  takes  place  from  collapse.  It  is  impossible  to  make  an  absolute 
diagnosis,  as  local  peritonitis  and  abscess  of  the  liver  are  characterized 
by  the  same  symptoms.  In  abscess  a  tumor  may  form  in  the  epigas- 
trium. It  may  occur  idiopathically,  but  it  frequently  occurs  in  septi- 
caemia, and  follows  trauma. 

Toxic  gastritis  is  allied  to  the  former  in  the  severity  of  general  symp- 
toms. It  is  the  result  of  the  swallowing  of  irritating  poisons,  of  which 
phosphorus,  arsenic,  bichloride  of  mercury,  and  caustic  alkalies  are  the 
most  common.  It  is  attended  by  inflammation  in  the  mouth,  oesoph- 
agus, and  stomach.  There  are  salivation  and  dysphagia,  and  constant 
vomiting  of  blood,  often  with  shreds  of  mucous  membrane.  The  patient 
is  restless,  and  may  have  convulsions  ;  collapse  rapidly  develops.  In 
mild  cases,  in  which  the  local  effects  of  the  corrosive  substance  have 
been  mitigated  by  proper  antidotes,  sloughs  occur,  leaving  behind 
ulcers  on  the  mucous  membrane,  which,  after  healing,  result  in  de- 
formity or  stenosis  of  the  oesophagus. 

Some  cases  are  attended  by  other  symptoms  peculiar  to  the  special 
poison.  Thus  with  arsenic  there  are  choleraic  symptoms  ;  in  phos- 
phorus-poisoning the  symptoms  come  on  late  after  its  ingestion,  and 
are  attended  by  jaundice  and  symptoms  of  acute  yellow  atrophy. 

Mycotic  and  diphtheritic  gastritis  occur  secondarily  to  typhoid  fever, 
pneumouia,  pyaemia,  smallpox,  and  sometimes  diphtheria.    The  mucous 


540  SPECIAL  DIAGNOSIS. 

membrane  may  be  covered  with  patches  in  areas  or  throughout  its 
whole  extent. 

Some  special  micro-organisms  irritate  the  gastric  mucosa,  as  the 
anthrax  bacillus  and  the  sarcinae  and  yeast  fungi  in  cancer  and  dilata- 
tion of  the  stomach.  Rarely  tuberculous  inflammation  with  ulceration 
takes  place,  and  other  micro-organisms  have  been  described.  Klebs 
found  the  bacillus  gastricus  with  numerous  spores  in  the  tubules,  as  a 
consequence  of  which  a  gastritis  was  set  up. 

The  mucous  membrane  itself  escapes  infection  from  micro-organisms 
because  of  the  character  of  its  secretion.  The  acid  gastric  juice  is 
antagonistic  to  and  causes  the  death  of  micro-organisms.  Tuberculo- 
sis, for  instance,  rarely  attacks  the  stomach  for  this  reason. 

Chronic  Gastritis. 

Causes.      1.   Previous  attacks  of  acute  gastritis. 

2.  The  local  irritation  of  badly  cooked  or  poorly  masticated  food, 
and  of  alcoholic  and  other  beverages. 

3.  The  local  irritation  of  urea  in  chronic  Bright' s  disease,  and  of 
products  of  putrefaction  in  constipation. 

4.  In  anaemia  chronic  gastritis  is  of  frequent  occurrence,  and  in 
venous  congestions  from  any  cause,  but  particularly  from  disease  of 
the  heart  or  diseases  which  interfere  with  the  portal  circulation.  It 
occurs  secondarily  to  diabetes,  gout,  rheumatism,  nephritis,  and  tuber- 
culosis. 

5.  It  is  a  constant  attendant  upon  local  disease  of  the  stomach,  as 
cancer,  dilatation,  and  ulcer,  and  of  local  disturbance  of  the  circulation. 

The  symptoms  are  those  of  chronic  indigestion.  There  is  a  dry, 
pasty,  or  salty  taste  in  the  mouth,  especially  in  the  morning.  The 
tongue  is  coated  over  its  entire  surface,  or  has  red  patches  at  the  base. 
The  papillae  of  the  tongue  are  always  swollen  and  its  edges  marked 
by  the  teeth.  Aphthae  recur  frequently.  The  lips  are  dry  and  often 
chapped.  The  appetite  is  poor  or  capricious.  Although  there  is  no 
great  thirst  the  patients  crave  fluids  with  their  meals,  and  acid  drinks 
are  grateful.  After  eating  there  is  a  feeling  of  oppression  and  dis- 
tention in  the  epigastrium  frequently  followed  by  belching.  The  gase- 
ous eructations  are  odorless  or  foul,  and  rancid  regurgitation  with 
pyrosis  is  frequent.  The  acidity  is  due  to  fatty  acids  and  not  to 
hydrochloric  acid,  as  in  hypersecretion.  Vomiting  is  invariably  pres- 
ent, but  occurs  irregularly.  It  is  usually  preceded  by  nausea.  The 
most  characteristic  form  is  that  in  which  mucus  is  vomited  in  the  morn- 
ing on  rising.  Constipation  usually  exists;  it  may  alternate  with  diar- 
rhoea.     There  are  flatulency  and  rumbling  in  the  intestines. 

General  Symptoms.  The  nervous  symptoms  are  the  most  pronounced. 
The  mental  activity  is  diminished,  there  is  a  feeling  of  languor  or  tor- 
por, especially  after  eating.  Headache  is  frequent  after  eating,  and 
the  patient  may  become  morose  and  hypochondriacal.  Attacks  of 
vertigo  are  common.  Itching  of  the  skin  and  coldness  of  the  extrem- 
ities are  not  rare.  Sleep  is  deeper  and  longer  than  is  natural,  but  is 
disturbed  by  dreams,  and  is  not  refreshing.      Yawning  is  frequent. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     541 

Pharyngitis  usually  attends  the  attack,  with  hacking  cough  and  expec- 
toration, or  hawking  of  mucus. 

The  pulse  may  be  weak  and  irregular,  and  at  times  there  is  an  even- 
ing rise  of  temperature.  The  urine  is  scanty,  high-colored,  and  usually 
loaded  with  urates. 

Three  forms  are  seen :  (1)  simple  chronic  gastritis  ;  (2)  chronic  mucous 
gastritis;  the  term  "  chronic  catarrh  of  the  stomach"  is  applied  to 
both  conditions.  If  the  condition  lasts  a  long  time,  it  results  in  (3) 
atony,  with  dilatation  of  the  stomach,  or  with  atrophy.  A  trophy,  or 
atrophic  gastritis,  is  secondary  to  the  chronic  form,  or  to  stenosis  of  the 
oesophagus,  or  to  cancer.  The  symptoms  are  those  of  pernicious  anae- 
mia. Cirrhosis  of  the  stomach  is  also  a  sequence  of  gastritis.  It  is 
rare,  and  the  symptoms  are  not  characteristic  of  a  special  lesion.  They 
are  those  of  the  primary  disease. 

Examination  of  the  Stomach-contents.  In  simple  gastritis  the  stom- 
ach, after  digestion  is  completed,  contains  a  small  amount  of  slimy 
fluid.  Hydrochloric  acid  is  diminished  in  quantity  after  a  test-break- 
fast ;  lactic  acid  and  the  fatty  acids  are  present,  as  previously  noted. 
Pepsin  and  the  milk-curdling  ferment  are  absent  or  diminished.  In 
mucous  gastritis  there  is  subacidity.  It  differs  from  the  simple  form 
in  the  excess  of  mucus  only.  In  atrophy  the  hydrochloric  acid  and 
pepsin  are  diminished,  or  absent  altogether  after  the  test-breakfast. 
The  fasting  stomach  is  empty.  There  are  no  fermentation  acids. 
Atrophy  must  be  distinguished  from  cancer  and  subacid  neuroses.  The 
latter  occur  in  younger  individuals  than  those  subject  to  atrophy.  A 
bloody  tinge  in  the  stomach-contents,  or  hemorrhage,  may  be  the  only 
distinguishing  mark  of  cancer.  Often  it  is  impossible  to  make  a 
diagnosis. 

The  diagnostic  features  of  chrouic  gastritis  are:  first,  long  duration; 
second,  persistence  of  local  symptoms  ;  third,  recurrence  of  local  symp- 
toms after  food,  the  symptoms  being  aggravated  by  stimulants,  or 
stimulating  food ;  fourth,  moderate  pain  j  fifth,  absence  of  cachexia ; 
sixth,  absence  of  tumor ;  seventh,  flatulency.  Hemorrhage  is  rare, 
and  there  may  or  may  not  be  vomiting,  while  the  quantity  of  hydro- 
chloric acid  is  variable.     Finally,  the  cause  is  usually  definite. 

Cancer  of  the  Stomach. 

The  clinical  symptoms  are  varied.  Gastric  cancer  may  occur  with- 
out any  symptoms  whatever,  and  be  discovered  after  death  from  other 
causes.  On  the  other  hand,  general  marasmus  and  cachexia  may  be 
present,  without  local  symptoms.  In  some  cases  the  gastric  symptoms 
are  slight,  and  obscured  by  the  symptoms  of  secondary  growth  in  the 
liver  or  peritoneum. 

Typical  cases  are  those  which  occur  late  in  life,  with  symptoms  of 
chronic  gastritis.  These  symptoms  may  continue  for  mouths  before 
anything  further  is  observed.  Gradually  the  uneasiness  and  discom- 
fort after  eating  increase  to  actual  pain.  Loss  of  appetite  is  marked, 
and  in  spite  of  careful  treatment  there  is  loss  of  flesh  and  strength. 
The  usual  vomiting  of  chronic  gastritis  gradually  becomes  more  fre- 


542  SPECIAL  DIAGNOSIS. 

quent.  The  general  appearance  of  the  vomitus  is  at  first  like  that  of 
chronic  gastritis.  Soon  it  becomes  streaked  with  blood,  or  a  moder- 
ately large  hemorrhage  may  take  place.  The  vomited  matter  is  dark 
in  color,  like  coffee-grounds  in  appearance.  The  relation  of  vomiting 
to  the  time  of  taking  meals  depends  upon  the  seat  of  the  disease.  If 
at  the  cardiac  end  of  the  stomach,  the  vomiting  may  take  place  at 
once.  If  in  the  greater  curvature,  within  twenty  minutes  or  one 
hour  and  a  half  after  taking  food.  If  at  the  pyloric  orifice,  the  vom- 
iting is  delayed  several  hours.  As  the  disease  advances,  and  obstruc- 
tion becomes  more  complete  at  the  cardiac  orifice,  food  is  immediately 
regurgitated,  unless  secondary  dilatation  of  the  oesophagus  takes  place. 
When  there  is  gastric  dilatation  the  vomiting  may  take  place  at  longer 
intervals  and  be  characteristic  of  the  vomitus  of  dilatation.  Consti- 
pation is  the  rule. 

Tumor.  After  the  symptoms  of  chronic  gastritis  have  continued  for 
some  time  without  relief  a  tumor  may  be  detected,  depending  upon  its. 
situation  and  size  (see  Tumors  of  Abdomen).  If  the  growth  is  situated  at 
the  cardiac  orifice  of  the  stomach,  it  is  often  impossible  to  detect  it.  If 
at  the  pyloric  orifice,  the  tumor  is  found  to  the  right  of  the  median  line 
above  the  umbilicus,  but  may  be  forced  down  by  the  weight  of  the 
stomach  and  felt  at  the  umbilicus.  When  dilatation  follows  pyloric 
tumor  it  may  be  still  lower  down,  as  in  a  case  of  the  writer's,  in  which, 
it  was  found  two  inches  below  and  to  the  right  of  the  umbilicus.  In 
tumor  of  the  greater  curvature  the  mass  is  detected  below  the  margin 
of  the  ribs  on  the  left  side,  and  may  be  as  low  down  as  the  umbilicus. 
If  the  greater  curvature  is  involved,  the  organ  usually  atrophies,  and 
hence  the  physical  signs  indicating  the  lower  border  of  the  stomach 
are  higher  up  than  in  health. 

Symptoms  due  to  Metastasis.  The  liver  is  the  most  frequent  seat  of 
secondary  growths.  The  organ  enlarges,  and  its  surface  is  covered  over 
with  nodules.  Jaundice  occurs  in  rare  instances.  The  enlarged  liver 
may  cover  the  stomach  and  hide  the  local  mass.  The  inguinal  glands 
enlarge.  At  times  there  is  enlargement  of  the  supra-clavicular  glands, 
suggestive  also  of  intra-abdominal  carcinoma,  from  other  causes. 

The  general  symptoms  are  those  of  emaciation  and  cachexia.  The 
ancemia  becomes  profound.  The  emaciation  is  extreme,  and  in  some 
cases  may  be  out  of  proportion  to  the  local  symptoms.  If  fever  occurs 
in  the  course  of  the  disease,  it  is  usually  due  to  secondary  accidents,  as 
suppuration  in  a  tumor,  or  perforation  with  septic  peritonitis.  The 
usual  course  of  the  temperature  is  normal  until  the  later  stages,  when 
it  is  subnormal. 

The  symptoms  of  cachexia  are  those  of  emaciation  and  ansemia. 
The  pallor  of  the  face  is  striking,  often.it  is  of  a  yellowish  and  straw- 
colored  hue.  It  must  not  be  confounded  with  jaundice  :  examination 
of  the  conjunctivae  is  usually  sufficient  to  distinguish  the  two.  The 
skin  is  flabby,  and  the  subcutaneous  fat  is  entirely  lost  ;  the  emacia- 
tion is  not  so  marked  as  in  cancer  of  the  oesophagus,  except  when  there 
is  complete  cardiac  stricture.  The  nutrition  of  the  skin  suffers,  boils 
are  common,  and  ulcers  may  occur.  Subcutaneous  hemorrhages  are 
seen  in  the  terminal  stages  on  the  backs  of  the  hands,  on  the  dorsum 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     543 

of  the  feet,  on  the  legs  and  arms.  There  is  slight  oedema  of  the 
ankles. 

General  atrophy  of  the  internal  organs  takes  place,  so  that  the  heart 
becomes  small ;  it  loses  its  strength,  the  patient  becomes  weaker  and 
weaker,  the  pulse  rapid  and  feeble. 

Examination  of  the  Stomach-contents.  Hydrochloric  acid  may  or  may 
not  be  absent,  depending  upon  the  amount  of  gastric  catarrh.  Lactic 
acid,  on  the  other  hand,  is  commonly  present  even  in  the  earliest 
stages,  and  when  associated  with  absent  HC1  is  very  diagnostic. 
Boas' s  test-breakfast  must  be  given.  For  an  accurate  diagnosis 
repeated  examinations  must  be  made.  Other  general  and  local  con- 
ditions, as  fevers  on  the  one  hand,  or  dilatation  on  the  other,  are 
attended  by  absence  of  hydrochloric  acid  at  times.  In  carcinoma  it 
is  the  persistence  of  the  absence  which  is  diagnostic.  Pepsin  and  the 
milk-curdling  ferment  are  not  changed.  Urine.  Indicau  in  increased 
amount,  acetone  and  diacetic  acids  may  be  present  in  the  urine  ;  other- 
wise there  is  no  change. 

Diagnosis.  In  the  diagnosis  of  gastric  cancer  the  following  must 
be  borne  in  mind  :  1.  The  age  of  the  patient.  2.  The  occurrence  of 
causeless  dyspepsia  without  relief.  3.  Rapid  loss  of  flesh  and  strength, 
with  cachexia.  4.  The  occurrence  of  pain  in  the  epigastrium,  contin- 
uous, increased  by  food,  but  not  relieved  by  vomiting,  as  in  ulcer,  and 
not  distinctly  localized.  5.  Tumor — hard,  circumscribed,  followed 
by  the  physical  signs  of  dilatation,  if  in  the  pylorus.  6.  Vomiting 
is  necessarily  associated  with  the  taking  of  food,  in  which  fragments 
of  cancer  may  be  found;  blood-cells  are  common;  they  may  be  detected 
on  microscopical  examination,  or  with  Gmelin's  test.  7.  Examination 
of  stomach- contents,  (a)  Except  in  dilatation  the  fasting  stomach  is 
empty  ;  (b)  hydrochloric  acid  often  absent,  whereas  lactic  acid  is  pre- 
sent ;  (c)  delayed  absorption  is  present,  indicated  by  motor  tests.  8. 
Hemorrhage.  In  small  amounts,  usually  of  characteristic,  coffee- 
ground  appearance.  9.  Metastases  — above  the  left  clavicle  ;  in  the 
liver  ;  in  the  inguinal  glands  ;  rarely  in  the  lungs  and  peritoneum. 
10.  Eichhorst  speaks  of  persistent  itching  of  the  skin  and  insomnia 
as  characteristic  symptoms.  11.  Finally,  the  comparatively  short 
duration  of  the  case.  Rarely  does  it  extend  over  a  period  of  two 
years. 

The  Significance  of  the  Tumor.  If  a  tumor  is  present,  it  is  necessary 
to  exclude  tumors  in  the  same  situation  from  other  causes.  This  is 
sometimes  difficult.  Indeed,  as  far  as  the  location  and  physical  char- 
acters are  concerned,  often  impossible.  The  most  pronounced  diag- 
nostic feature  of  tumor  of  the  pylorus  is  the  occurrence  of  secondary 
dilatation  of  the  stomach.  For  a  differential  diagnosis  of  tumors  in 
this  region,  see  Palpation  of  Abdomen. 


544 


SPECIAL  DIAGNOSIS. 


Differential  Diagnosis  of  Gastric  Cancer,  Gastric  Ulcer,  and 
Chronic  Gastritis.    (Welch.) 


Gasteic  Cancer. 

1.  Tumor  is  present  in  three- 
fourths  of  the  cases. 

2.  Rare  under  forty  years  of 
age. 


3.  Average  duration  about  one 
year,  rarely  over  two  years. 

4.  Gastric  hemorrhage  fre- 
quent, hut  rarely  profuse  ; 
most  common  in  the  ca- 
chectic stage. 


5.  Vomiting  often  has  the  pe- 
culiarities of  that  of  dilata- 
tion of  the  stomach. 


6.  Free  hydrochloric  acid  usu- 
ally absent  from  the  gastric 
contents  in  cancerous  dila- 
tation of  the  stomach.  Lac- 
tic acid  much  increased. 

7.  Cancerous  fragments  may 
be  found  in  the  washings 
from  the  stomach  or  in  the 
vomit  (rare). 

8.  Secondary  cancers  may  be 
recognized  in  the  liver,  the 
peritoneum,  the  lymphatic 
glands,  and,  rarely,  in  other 
parts  of  the  body. 

9.  Loss  of  flesh  and  strength 
and  development  of  ca- 
chexia usually  more  mark- 
ed and  more  rapid  than  in 
ulcer  or  in  gastritis,  and  less 
explicable  by  the  gastric 
symptoms. 

10.  Epigastric  pain  is  often 
more  continuous,  less  de- 
pendent upon  taking  food, 
less  relieved  by  vomiting, 
and  less  localized  than  in 
ulcer. 

11.  Causation  not  known. 


12.  No  improvement,  or  only 
temporary  improvement,  in 
the  course  of  the  disease. 


Gastric  Ulcer. 
Tumor  rare. 


May  occur  at  any  age  after 
childhood.  Over  one-half 
of  the  cases  under  forty 
years  of  age. 

Duration  indefinite  ;  may  be 
for  several  years. 

Gastric  hemorrhage  less  fre- 
quent than  in  cancer,  but 
oftener  profuse  ;  not  uncom- 
mon when  the  general 
health  is  but  little  im- 
paired. 

Vomiting  rarely  referable  to 
dilatation  of  the  stomach, 
and  then  only  in  a  late 
stage  of  the  disease. 

Free  hydrochloric  acid  usu- 
ally present  in  the  gastric 
contents. 


Absent. 


Absent. 


Cachectic  appearance  usually 
less  marked  and  of  later 
occurrence  than  in  cancer, 
and  more  manifestly  de- 
pendent upon  the  gastric 
disorders. 


Pain  is  often  paroxysmal, 
more  influenced  by  taking 
food,  oftener  relieved  by 
vomiting,  and  more  sharply 
localized  than  in  cancer. 


Causation  not  known. 


Sometimes  a  history  of  one  or 
more  previous  similar  at- 
tacks. The  course  may  be 
irregular  and  intermittent. 
Usually  marked  improve- 
ment by  regulation  bf  diet. 


Chronic  Catarrhal  Gastritis. 
No  tumor. 

May  occur  at  any  age. 

Duration  indefinite. 
Gastric  hemorrhage  rare. 


Vomiting   may   or    may   not   be 
present. 


Free   hydrochloric   acid   may  be 
present  or  absent. 


Absent. 


Absent. 


When  uncomplicated,  usually  no 
appearance  of  cachexia. 


The  pain  or  distress  induced  by 
taking  food  is  usually  less  severe 
than  in  cancer  or  ulcer.  Fixed 
points  of  tenderness  usually  ab- 
sent. 


Often  referable  to  some  known 
cause,  such  as  abuse  of  alcohol, 
gormandizing,  and  certain  dis- 
eases, as  phthisis,  Bright's  dis- 
ease, cirrhosis  of  the  liver,  etc. 

May  be  a  history  of  previous  simi- 
lar attacks.  More  amenable  to 
regulation  of  diet  than  is  cancer. 


Cases  of  cancer  of  the  stomach  may  present  only  symptoms  of 
anaemia.  In  this  manner  the  disease  has  been  confounded  with  per- 
nicious anaemia.  The  blood  is  never  reduced  in  cancer  to  the  degree 
it  is  in  pernicious  anaemia,  nor  does  it  present  the  characteristics 
found  in  anaemia. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     545 


Ulcer  of  the   Stomach. 

Simple  round  ulcer  of  the  stomach  may  occur  at  any  age,  but  is 
most  common  in  young  anaemic  women.  It  may  be  the  result  of  an 
erosion  of  hemorrhagic  infarcts  by  the  gastric  juice.  Stockton  believes 
it  to  be  a  neuropathic  change. 

The  Symptoms.  The  symptoms  are  variable.  The  cases  have 
been  divided  by  Welch  into  four  classes :  (1)  Those  in  which  there  are 
no  symptoms  whatever,  the  ulcer  having  been  found  after  death  from 
other  diseases  ;  (2)  no  symptoms  until  the  sudden  occurrence  of  hemor- 
rhage, or  perforation  ;  (3)  the  symptoms  of  chronic  gastritis  or  gas- 
tralgia  only  ;  (4)  typical  cases,  with  the  characteristic  symptoms, 
pain,  hemorrhage,  and  vomiting.  The  symptoms  of  gastric  ulcer  may 
develop  suddenly. 

Pain.  The  pain  is  localized  ;  it  is  usually  confined  to  a  small  area 
in  the  epigastrium.  It  may  be  seated  behind  the  cartilage  of  the  sixth 
and  seventh  ribs,  or  may  be  complained  of  in  the  back,  between  the 
eighth  and  ninth  dorsal  vertebra?,  extending  as  low  down  as  the  first 
and  second  lumbar.  It  is  of  a  burning  or  gnawing  character,  is 
increased  by  food,  and  comes  on  in  from  two  to  ten  minutes  after  the 
ingestion  of  food.  It  is  relieved  by  vomiting,  or  after  the  act  of  diges- 
tion is  completed  ;  but  a  persistent,  dull  pain  or  a  feeling  of  soreness 
remains.  In  addition  to  the  ordinary  pains,  there  may  be  attacks  of 
gastralgia.  The  pain  is  increased  by  pressure.  It  may  be  modified 
by  the  position  of  the  patient.  It  may  be  relieved  by  lying  on  the 
back  when  the  ulcer  is  in  the  anterior  wall ;  or  relieved  by  lying  on 
the  abdomen  when  in  the  posterior  wall. 

Vomiting.  Vomiting  occurs  shortly  after  the  ingestion  of  food.  It 
is  not  attended  by  retching.     The  vomited  matter  may  contain  blood. 

The  vomited  matter  and  the  contents  of  the  stomach  contain  hydro- 
chloric acid,  which  may  be  in  excess.  Eichhorst  thinks  it  is  always 
in  excess. 

Hemorrhage.  Blood  in  the  vomitus  gives  it  a  brown  or  reddish  color. 
It  may  be  detected  by  the  usual  methods.  Hemorrhage  may  occur, 
however,  independently  of  the  act  of  vomiting.  It  varies  in  amount 
from  half  a  pint  to  a  quart.  It  may  be  so  severe  as  to  cause  collapse. 
Sometimes,  instead  of  being  discharged  as  a  profuse  hemorrhage,  the 
blood  may  gradually  ooze  from  the  ulcer  and  collect  in  the  stomach 
before  being  vomited.  It  is  then  altered  by  the  acid  gastric  juice. 
Sometimes  the  blood  is  not  vomited,  but  passed  by  stool,  which  is  then 
tarry.  Tarry  stools  also  follow  the  vomiting  of  blood.  In  the  course 
of  ulcer  a  hemorrhage  may  be  so  severe  that  death  takes  place  before 
vomiting  occurs.      The  stomach  is  then  found  to  be  filled  with  blood. 

The  stomach  bougie  should  not  be  used  ;  the  nature  of  the  contents 
must  be  determined  by  an  examination  of  the  vomited  matter. 

The  General  Symptoms.  If  the  cases  are  of  long  standing,  the 
face  is  anxious  and  the  lines  are  sharpened.  If  there  is  much  hemor- 
rhage, anaemia  ensues.  There  is  not  much  wasting  and  no  fever. 
Chronic  dyspepsia  and  constipation  may  attend  it  during  the  intervals 
in  which  the  severe  symptoms  are  in  abeyance.     The  period  of  abey- 

35 


546  SPECIAL  DIAGNOSIS. 

ance  varies  and  the  symptoms  may  come  on  without  cause,  as  in  gastric 
crises,  during  which  time  the  vomiting  may  persist  for  two  or  three 
days.  I  saw  a  young  girl  of  twenty  years  with  most  severe  gastric 
hemorrhage  and  classical  symptoms  of  ulcer.  With  careful  treatment 
she  improved.  After  marriage  she  remained  well  until  pregnancy. 
During  the  first  periods  of  this  condition  vomiting  was  extreme  ;  it 
then  subsided,  whereupon,  without  warning,  a  gastric  crisis  took  place. 
The  vomiting  of  blood  continued  for  many  days,  and  the  symptoms  of 
gastric  ulcer  remained  for  a  month. 

One  of  the  characteristic  features  of  the  disease  is  the  recurrence  of 
symptoms  after  a  long  period  of  abeyance.  A  patient  under  my  care 
during  the  last  ten  years  has  had  three  undoubted  attacks.  It  is  pos- 
sible that  during  each  period  ulcers  healed,  to  be  followed  after  a  time 
by  the  occurrence  of  new  ulcers. 

Diagnosis.  The  diagnostic  features  are :  1.  The  age.  2.  The  long 
duration.  3.  The  occurrence  of  emaciation  up  to  a  certain  point  only; 
most  of  the  patients  are  under-weight  and  have  a  gaunt  look,  particu- 
larly males.  4.  The  characteristic  pain.  5.  The  vomiting.  6.  The 
hemorrhage.  7.  The  periods  of  relief  from  symptoms.  8.  The 
absence  of  marked  nervous  symptoms  which  attend  gastric  neuroses. 
9.  The  absence  of  dilatation  of  the  stomach.  10.  The  hyperacidity 
of  the  gastric  juice. 

The  Accidents  of  Ulcer  of  the  Stomach.  1.  The  occurrence  of  per- 
foration. Sudden  severe  pain,  with  collapse.  The  pain  is  usually  in 
the  epigastrium,  but  may  be  in  the  back  as  high  as  the  seventh  or 
eighth  dorsal  vertebra. 

2.  Hemorrhage,  which  may  cause  death  immediately,  with  either 
vomiting  of  blood  or  retention  in  the  stomach. 

3.  With  healing  of  the  ulcer,  stenosis  at  the  pyloric  orifice  may  take 
place,  with  subsequent  dilatation  of  the  stomach. 

Dilatation  of  the  Stomach  (G-astrectasia). 

It  is  caused  by  obstruction  at  the  pyloric  orifice,  either  from  cancer, 
the  cicatrix  of  an  ulcer,  or  fibrous  stricture.  It  follows  atony  and 
degeneration  of  the  walls  of  the  stomach  which  occur  in  the  course  of 
chronic  gastritis.  It  may  attend  paralysis  of  the  stomach.  Excessive 
eating  and  drinking  are  the  only  probable  cause  independent  of  organic 
disease.  The  dilatation  may  be  acute.  The  term  acute  paralytic  dis- 
tention is  also  applied  to  this  condition.  The  cases  are  extremely  rare. 
There  is  sudden  enlargement  of  the  upper  portion  of  the  abdomen, 
with  pressure  upon  the  surrounding  structures.  The  heart  is  dislocated 
and  its  action  is  very  much  increased,  causing  collapse,  and  death 
attends  the  occurrence.  At  first  there  may  be  some  belching,  but  the 
patient  is  soon  unable  to  remove  the  gas,  and  suffers  from  extreme 
discomfort,  palpitation,  and  dyspnoea.  The  vomiting  may  occur  at 
once  or  later.  It  is  persistent  and  excessive.  On  physical  examination 
the  stomach  yields  the  same  physical  signs  as  in  chronic  dilatation. 

Chronic  dilatation  develops  slowly.  (The  symptoms  of  it  are  super- 
imposed upon  the  causal  disease.)     The  symptoms  are  marked  dys- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     547 

pepsiawith  flatulency,  pyrosis  and  other  symptoms  of  fermentation. 
The  tongue  is  pale  and  furred,  or  red,  smooth,  and  shiny;  or  it  may 
be  soft  and  flabby.  If  frequent  vomiting  has  attended  the  causal 
disease,  it  now  occurs  at  longer  intervals;  the  amount  is  excessive, 
greater  than  the  normal  stomach  would  hold,  and  is  made  up  of  par- 
tially digested  and  fermented  food  and  large  amounts  of  mucus.  The 
stomach-contents  contain  sarcinee,  torulfe,  and  other  products  of  fer- 
mentation. Hydrochloric  acid  is  usually  absent,  but  there  is  a  large 
excess  of  lactic  and  fatty  acids.  With  the  above  symptoms  the  patient 
loses  flesh  and  strength;  becomes  irritable,  depressed,  and  more  or  less 
melancholy.  The  patient  is  subject  to  vertigo  and  to  attacks  of  noc- 
turnal asthma.  The  nervous  symptoms  of  chronic  gastritis  are  also 
present.  Sleeplessness  is  quite  common.  In  some  cases  there  is 
excessive  thirst  because  of  the  small  amount  of  nutriment  and  fluid 
absorbed.  Palpitation  and  irregularity  are  common,  and  dyspnoea  may 
occur  on  account  of  the  distention.  Tetany  has  been  observed  in  cases 
of  dilatation,  especially  after  lavage. 

Physical  Examination.  The  diagnosis  is  not  complete  without  phys- 
ical examination.  On  inspection  the  abdomen  is  large  and  prominent, 
and  the  outline  of  the  stomach  can  sometimes  be  seen.  Peristaltic 
movements  of  the  organ  are  often  seen.  The  movement  is  from  left 
to  right.  The  heart  is  lifted  upward.  On  palpation  the  peristalsis 
can  be  felt,  and  with  one  hand  on  the  stomach,  tapping  with  the 
other,  a  splashing  .sound  can  be  detected.  Or  the  hand  may  be 
placed  over  the  stomach  (patient  standing)  and  the  body  quickly 
shaken.  On  palpation  the  striking  or  pushing  hand  should  be  com- 
pressed over  the  false  ribs.  A  tumor  can  sometimes  be  felt  in  the 
region  of  the  pylorus,  or  below  the  umbilicus.  On  percussion,  when 
the  stomach  contains  gas  a  tympanitic  note  is  heard.  After  drinking- 
water  dulness  may  be  detected  between  gastric  and  intestinal  tympany 
if  the  patient  stands  up.  The  dull  note  disappears  when  he  resumes 
the  recumbent  posture.  Before  taking  water  tympany  is  not  so 
marked  in  the  upright  as  in  the  recumbent  posture,  because  the 
stomach  is  dragged  back  or  down.  The  tympany  extends  high  up  in 
the  chest  on  the  left  side,  so  that  Traube's  half-moon  space  is  exag- 
gerated. It  may  extend  as  high  as- the  fourth  interspace  on  the  left 
side.  Cardiac  dulness  is  increased  and  the  apex  of  the  heart  is  lifted 
upward  and  to  the  left.  In  the  axillary  region  the  tympany  may 
extend  as  high  as  the  sixth  rib.  There  is  usually  atrophy  of  the 
spleen,  so  that,  unless  very  careful,  light  percussion  is  performed, 
the  splenic  dulness  cannot  be  brought  out.  The  lower  limit  extends 
below  the  transverse  umbilical  line,  and  may  even  extend  midway  to 
the  pubis.  If  there  is  gastroptosis,  the  half-moon  space  becomes  dull 
on  percussion,  the  stomach  tympany  falling  to  a  lower  level.  On  aus- 
cultation succusaion  can  easily  be  elicited.  Sometimes  the  sound  is 
sizzling  as  if  there  were  effervescence.  Heart-sounds  may  be  trans- 
mitter! clear  and  metallic  over  the  tympanitic  stomach.  With  aus- 
cultatory percussion  the  border  of  the  stomach  can  often  be  defined  accu- 
rately. Percussion  must  be  commenced  far  away  from  the  stomach- 
limits  and  conducted  toward  it.    (See  Examination  of  Abdomen.) 


548  SPECIAL  DIAGNOSIS. 

Rupture  of  the  Stomach.  This  may  occur  in  diseased  conditions  of 
its  walls,  or  in  the  healthy  stomach  from  external  violence.  Pain  fol- 
lowed by  collapse  occurs,  with  almost  immediate  death. 

Functional  Disorders  of  the  Stomach. 

The  Neuroses.  Functional  disturbances  of  the  stomach  are  due  to 
impairment  of  the  motor  power  of  the  stomach,  impairment  of  the 
secretory  function  and  of  the  sensory  function.  The  following  table  of 
Ewald,  as  given  by  that  distinguished  authority,  is  a  classification  of 
the  various  neuroses  midway  between  the  symptomatic  and  the  etio- 
logical : 

The  Neuroses  of  the  Stomach. 
1.  Conditions  of  Irritation. 
a.  Sensory.  b.  Secretory.  c.  Motor. 

Hyperesthesia.  Hyperacidity.  Eructation. 

Nausea.  Hypersecretion  Pyrosis. 

Hyperorexia.  Vomiting. 

Anorexia  ex  hyperesthesia.  Colic. 

Parorexia.  Tormina  ventriculi. 

Gastralgla. 

2.  Conditions  of  Depression. 

Anaesthesia.  Anacidity.  Atony. 

Polyphagia.  Insufficiency  of  the  pylorus  and  cardia. 

3.  Mixed  Form. 
Gastro-intestinal  neurasthenia  (dyspepsia  nervosa). 

4.  Reflexes  from  Other  Organs  upon  the  Gastric  Nerves. 

Reflexes  from  the  brain,  eyes,  spinal  cord,  kidneys,  liver,  sexual  organs,  and  intestines 
manifest  themselves  in  the  forms  mentioned  in  1  and  2. 

It  must  not  be  supposed  that  each  of  the  above-named  symptoms 
occurs  in  an  individual,  or  that  functional  disturbances  may  be  limited 
to  alterations  of  the  sensory  and  secretory  or  the  motor  apparatus, 
respectively.  They  do  not  occur,  as  Ewald  states,  as  distinct  inde- 
pendent diseases,  but  usually  in  groups,  "  either  appearing  simulta- 
neously or  closely  following  one  another  during  the  course  of  the 
malady,  passing  before  us  like  an  ever-changing  scene."  They  may 
arise  directly  from  disease  of  the  stomach,  or  renexly  from  disease 
of  other  organs,  as  the  brain,  the  spinal  cord,  uterus,  kidneys,  liver, 
eyes,  and  nose. 

jEtiology.  G-astric  neuroses  are  of  most  frequent  occurrence  in 
women,  especially  during  the  years  from  puberty  to  the  menopause. 
In  both  sexes  they  are  of  most  frequent  occurrence  after  the  age  of 
twenty  years,  because  individuals  are  subjected  to  the  operation  of 
causes  which  lead  to  neuroses  at  this  period  of  life.  The  gastric  neu- 
roses occur  in  all  conditions  of  patients.  They  are  more  likely  to 
occur  in  those  who  are  poorly  nourished  or  anrernic  ;  although  persons 
who  are  distinctly  robust  may  also  suffer  from  gastric  neuroses.  While 
more  common  in  the  residents  of  cities,  they  may  occur  in  farmers 
and  others  accustomed  to  an  open-air  life.  Although  we  are  often  est 
called  upon  to  treat  them  among  the  better  classes,  nevertheless  a  large 
number  of  cases  are  seen  among  the  poorer  classes.  To  analyze  more 
closely  the  predisposing  causes,  we  have  to  study  individually  all  con- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     549 

ditions  and  circumstances  in  life  which  lead  to  wear  and  tear,  as  in 
business  or  social  affairs.  The  causes  which  Beard  and  others  have 
forcibly  pointed  out  as  factors  in  the  production  of.  neurasthenia  are 
especially  prevalent  in  this  country. 

In  men,  excessive  devotion  to  business,  or  dissipation;  in  women 
excesses  in  social  life,  or  the  restraint  of  home  cares,  with,  unhappily, 
too  often,  the  irritation  of  marital  relations,  are  the  predisposing 
factors  which  lead  to  the  development  of  this  class  of  cases.  Often 
patients  in  the  large  cities  are  subject  to  the  neuroses  in  the  spring 
after  the  dissipations  of  the  winter.  Behind  this  excess  there  is  no 
doubt  that  a  nervous  temperament  is,  in  the  majority  of  cases,  respon- 
sible for  the  bringing  out  of  the  symptoms,  particularly  if,  combined 
with  this  temperament,  the  patients  live  in  an  unhygienic  way  in 
regard  to  exercise,  ventilation  of  their  dwelling-places,  and  drainage, 
combined  with  improper  diet. 

Symptoms.  With  the  gastric  neuroses  other  symptoms  of  neuras- 
thenia are  present,  and  the  patient  may  seek  advice  for  these  symptoms, 
such  as  headaches  of  various  kinds,  changes  in  his  or  her  mental  con- 
dition, vertigo,  insomnia,  neuralgias,  and  all  forms  of  paresthesia. 
Intimately  connected  with  the  neurasthenic  state  is  that  of  hysteria, 
and  therefore  in  gastric  neuroses  hysterical  manifestations  are  most  com- 
mon. 'It  may  be  impossible  completely  to  define  the  border  line  be- 
tween neurasthenia  and  hysteria,  and  the  gastric  symptoms  of  the 
former  are  the  gastric  symptoms  of  the  latter.  While,  therefore,  gen- 
eral neurasthenic  symptoms  are  prominent,  in  order  to  reach  a  diagnosis 
upon  which  proper  lines  of  treatment  can  be  based  the  condition  of 
the  individual  must  be  viewed  as  a  whole,  and  no  one  symptom  or 
group  of  symptoms  exaggerated  in  our  minds. 

Ewald  has  divided  the  neuroses  into  those  which  arise  from  irrita- 
tion, and  those  which  arise  from  depression.  The  first  result  of  irrita- 
tion is  hyperwsthsia-  of  the  stomach,  which  is  indicated  by  a  feeling  of 
fulness  and  tension,  and  of  nausea.  The  sensation  is  allied  to  the  nor- 
mal, and  is  also  seen  in  chronic  gastritis,  as  well  as  in  hysteria,  menin- 
geal irritation,  cerebral  tumors,  and  other  diseases  of  the  nervous 
system.  The  increased  irritability  is  such  that  the  gentlest  irritant 
excites  discomfort  or  painful  sensation.  There  is  a  continuous  sensa- 
tion of  heat  or  cold,  of  gnawing,  or  pulling,  or  burning  in  the  organ. 
The  local  sensation  reflexly  influences  the  physical  life  of  the  patent, 
so  that  hypochondriasis  in  some  form  attends  it.  The  sensations  may 
be  relieved  by  food,  to  become  worse  if  the  stomach  is  emptied,  although 
in  the  larger  number  of  cases  the  trouble  is  aggravated  during  diges- 
tion. The  sensations  are  likely  to  be  aggravated  by  fasting  a  longer 
period  than  usual,  or  by  restriction  of  the  diet.  Excesses  may  aggra- 
vate them,  and,  on  the  other  hand,  they  are  said  to  follow  debilitating 
states.  Some  foods,  such  as  shell-fish,  crabs  and  lobsters,  or  oysters, 
and  strawberries,  are  likely  to  increase  the  peculiar  sensations  in  the 
epigastrium,  exciting  mild  depression,  or  burning,  or  even  nausea. 
The  excitation  from  these  foods  is  usually  due  to  peculiar  idiosyncrasies 
of  the  individual.  On  ;iccount  of  the  same  idiosyncrasies  pruritus, 
erythema,  and  urticaria  occur,  with  headache  and  some  fever. 


550  SPECIAL  DIAGNOSIS. 

Deviations  from  the  Sense  of  Hunger.  When  hunger  is 
exaggerated  it  is  known  as  boulimia,  or  hyper  or  exia.  It  may  be 
temporary  or  permanent.  When  permanent  it  is  obstinate,  weaken- 
ing, and  exceedingly  unpleasant.  It  may  occur  alone  or  be  a  symp- 
tom of  various  diseases  of  the  nervous  system,  as  manifest  disease  of 
the  brain,  neurasthenia,  hysteria,  aud  psychoses.  It  complicates  such 
disorders  as  diabetes,  and  may  be  of  temporary  duration  in  conva- 
lescence from  acute  disease.  The  disorder  accompanies  migraine,  or 
hypochondriasis,  and  exophthalmic  goitre.  Analogous  to  it  is  perver- 
sion of  the  appetite,  as  seen  in  pregnancy,  in  children,  and  in  mental 
disorders. 

Anorexia.  Loss  of  appetite,  or  repugnance  to  food.  In  the  first 
instance,  there  is  simply  loss  of  appetite ;  in  the  second,  there  is  repug- 
nance toward  food,  or  nausea  at  the  sight  of  it.  Loss  of  appetite  accom- 
panies dyspepsia  iu  all  forms.  In  the  gastric  neuroses  it  occurs  spon- 
taneously, or  is  due  to  hyperesthesia  of  the  stomach,  and  therefore 
may  arise  from  central  or  peripheral  conditions  of  irritation.  It  is 
commonly  seen  following  central  nerve  perturbation.  The  patient  is 
hungry,  and  sits  down  to  the  meal  fully  prepared  to  satisfy  himself. 
The  first  mouthful  is  at  once  followed  by  anorexia,  which  may  almost 
amount  to  nausea.  On  account  of  the  loss  of  appetite  or  repugnance 
the  patient  eats  less  aud  less  of  solid  food,  which  soon  results  in  disturb- 
ance of  nutrition  affecting  the  higher  centres.  On  the  other  hand, 
profound  mental  disturbance  may  be  an  exciting  cause,  so  that  after 
the  death  of  a  friend,  or  shock  of  any  kind,  the  patient  is  unable  to 
take  food.  Loss  of  appetite  may  be  the  only  manifestation  of  the 
gastric  neurosis,  but  because  nutrition  is  so  seriously  interfered  with 
it  soon  results  in  other  local  or  general  symptoms.  Fenwick  points 
out  that  its  relationship  to  emaciation  and  enfeeblement  is  such  that 
grave  organic  diseases  may  be  simulated.  Thus  it  may  be  mistaken 
for  phthisis,  and  general  examination  alone  is  sufficient  to  distin- 
guish it. 

Gastralgia.  Pain  in  the  stomach  occurs  in  organic  disease,  as  in 
ulcer  or  cancer,  or  forms  of  gastritis.  It  also  attends  gastric  neu- 
rosis, and  may  be  the  only  symptom  of  this  neurasthenic  state.  Such 
pain  is  functional,  and  is  found  in  anaemic,  neurotic  women.  It  may, 
however,  occur  in  all  classes.  It  is  characterized  by  sudden  pain  in  the 
epigastrium,  usually  without  regularity,  though  at  times  it  may  be  dis- 
tinctly periodic.  There  may  not  be  any  definite  relationship  between 
the  attack  of  pain  and  the  taking  of  food,  though  it  is  most  apt  to 
occur  when  the  stomach  is  empty.  Some  kinds  of  food  may  aggra- 
vate it,  though,  in  general,  eating  relieves  the  pain.  If  the  epigas- 
trium is  examined,  it  will  be  found  to  be  free  from  tenderness,  and 
indeed  pressure  with  the  palm  of  the  hand  may  give  relief.  The  pain 
is  of  an  agonizing  character,  sometimes  sharply  localized,  or  again 
diffuse.  It  may  even  resemble  the  girdle-sensation.  On  account  of 
the  severity  of  the  pain  the  patient  may  be  compelled  to  double  him- 
self up  to  relax  the  abominal  muscles.  The  breath  is  short,  and  speak- 
ing is  done  in  a  whisper.  The  attack  is  attended  by  more  or  less 
collapse,  aud  the  patient  may  complain  of  the  sensation  of  impending 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     551 

death.  There  is  pallor  of  the  face,  which  is  distorted  with  pain,  and 
the  brow  is  covered  with  perspiration.  The  pain  may  radiate  along 
the  spinal  nerves  in  close  situation  to  the  stomach,  and  there  is  often 
vigorous  pulsation  of  the  abdominal  aorta. 

The  attack  may  last  but  a  few  minutes  or  continue  for  hours.  It 
sometimes  terminates  suddenly  with  vomiting,  or  is  relieved  as  soon  as 
food  is  taken.  After  the  attack  the  patient  is  exhausted  and  relaxed, 
and  passes  an  abundance  of  urine  of  low  specific  gravity. 

The  gastralgias  that  are  due  to  disease  of  the  central  nervous  system 
are  often  most  puzzling.  Rosenthal  has  written  exhaustively  on  this 
subject.  Types  of  gastralgia  of  this  character  are  seen  in  the  gastric 
crises  of  tabes,  first  described  by  Charcot.  Recent  observers  have 
found  that  it  is  due  to  sclerotic  degeneration  of  the  vagus  nucleus. 
The  patient  is  suddenly  seized  with  severe  pains,  which  may  begin  in 
the  groin  and  ascend  along  both  sides  of  the  abdomen  to  the  epigas- 
trium, to  which  point  they  are  fixed.  Pain  in  the  shoulders  occurs  at 
the  same  time.  The  pains  are  characteristic  of  lumbar  ataxia  in  their 
lightning-like  rapidity.  With  the  pain  the  heart's  action  is  increased 
in  rapidity  and  force.  There  is  no  rise  in  temperature.  At  the  same 
time  there  is  uninterrupted  and  painful  vomiting,  which  is  attended 
by  nausea  and  vertigo.  The  gastric  pain  may  continue  uninterruptedly 
for  two  or  three  days.  It  belongs  to  the  pre  ataxic  period,  so  called, 
but  is  almost  sure  to  continue  throughout  the  whole  course  of  the  dis- 
ease. The.  nature  of  the  stomach-contents  bears  no  relation  to  the 
pain;  the  frequency  is  variable.  The  pains  may  recur  at  long  periods, 
or  as  frequently  as  once  a  month  or  once  a  week.  Another  special 
characteristic  is  the  sudden  relief  that  is  given  without  cause. 

Neurasthenic  Gastralgia.  Neurasthenic  gastralgia  occurs  in  patients 
who  are  suffering  from  neurasthenia,  and  is  divided  by  Rosenthal  into 
two  forms,  the  one  irritative,  the  other  depressant ;  these  are  related 
by  transitional  forms.  The  early  symptoms  of  neurasthenia  (q.  v.), 
particularly  in  the  irritative  form,  with  painful  points  in  the  nape  of 
the  neck  and  between  the  scapulse,  or  often  lower  down  on  the  verte- 
brae, with  neuralgias  and  paresthesia  in  the  upper  and  lower  extremi- 
ties, are  attended  by  periodical  gastralgia.  The  gastralgia  is  charac- 
terized by  a  boring  sensation  which,  during  the  attack,  radiates  over 
the  lower  ribs  to  the  median  line.  It  is  accompanied  by  vasomotor 
symptoms  and  symptoms  of  cerebral  ansemia.  In  the  depressant  form 
the  patient  complains  of  weight  and  fulness,  or  a  dragging  sensation 
after  eating,  which  is  constant  instead  of  paroxysmal.  The  neuralgic 
pains  are  not  so  marked,  motor  exhaustion  is  not  so  prominent,  and 
the  pain  in  the  back  is  not  so  intense  as  in  other  varieties.  In  both 
instances  on  deep  pressure  over  the  region  of  the  nerve-plexuses  which 
follow  the  bloudvessels  in  the  abdomen  there  is  sharp  and  unpleasant 
pain  radiating  to  the  epigastrium.  Burkart  considers  these  painful 
points  to  be  present  in  all  cases,  while  Richter  believes  that  pressure 
over  the  stomach  and  abdomen  is  not  painful.  With  such  pain 
there  is  usually  increased  pulsation  of  the  abdominal  aorta,  particu- 
larly during  the  time  of-  the  paroxysm.  In  neurasthenic  gastralgias 
there  are  increased  sensitiveness  to  the  electrical  current  and  increased 


552  SPECIAL  DIAGNOSIS. 

irritability    of  the  sensory  nerves  of  the  trunk,  which  may  also  be 
extended  to  the  limbs. 

Neurasthenic  gastralgia  must  be  distinguished  from  the  gastralgia  of 
organic  disease  and  the  gastralgia  of  hysteria.  The  gastralgia  of 
organic  disease  is  recognized  by  observing  the  condition  of  the  stomach 
when  fasting  and  by  studying  the  secretion.  In  organic  disease  there 
is  retarded  digestion  ;  in  gastric  neurosis  digestion  is  completed  in  the 
normal  limit  of  time,  seven  hours.  Hysterical  gastralgias  are  recog- 
nized by  the  presence  of  the  usual  symptoms  of  hysteria,  in  which  the 
psychical  factors  occupy  a  prominent  place,  associated  with  convulsions, 
paralyses,  pupillary  inequalities,  hemiansesthesia,  and  electrical  sensi- 
bility. Most  characteristic,  however,  is  the  alternation  of  hysterical 
gastralgias  with  neuralgia,  or  neuroses  in  other  organs. 

Hyperacidity  and  Hypersecretion.  Hyperacidity  is  the  increase  of 
the  normal  amount  of  hydrochloric  acid  secreted,  due  to  a  neurosis  of 
the  secretory  function.  Hyperacidity  begins  when  the  amount  of  acid 
in  the  fluid  withdrawn  from  the  stomach  in  the  usual  way  is  between 
60  and  70  per  cent.  It  must  not  be  forgotten  that  it  is  a  symptom  of 
gastric  ulcer,  but  it  exists  as  a  neurosis  independent  of  any  organic 
lesion  of  the  stomach.  It  has  been  observed  in  nervous  diseases,  as 
hysteria  and  melancholia,  and  as  a  reflex  symptom  in  gallstones  and 
renal  calculus. 

Hypersecretion  occurs  in  two  forms,  the  periodical  and  constant.  The 
acid  is  not  necessarily  increased.  The  periodical  occurs  after  eating  ; 
it  has  no  direct  connection  with  food.  It  is  seen  in  neurasthenia  and 
locomotor  ataxia.  In  chronic  hypersecretion  the  gastric  juice.,  which 
is  usually  hyperacid,  is  in  excess,  so  that  the  fasting  stomach  may  con- 
tain large  quantities,  even  to  a  pint  and  a  half,  without  food  and  only 
slightly  tinged  by  bile.  In  chronic  hypersecretion  the  digestion  of 
starches  is  delayed,  but  that  of  albuminoids  is  very  prompt.  After 
an  abundant  meal  consisting  of  meat  and  starches  the  meat  disappears 
entirely.  Hypersecretion  occurs  in  about  half  of  all  the  stomach  dis- 
orders, according  to  Riegel.  It  is  more  common  in  men  than  in 
women.  The  acid  fluid  causes  the  hypersesthetic  conditions  in  the 
gastric  region  previously  described.  Pain  and  eructation,  heartburn 
or  gastralgia,  vomiting  of  sour  masses,  occur  with  the  digestive  dis- 
turbances of  chronic  gastritis.  The  tongue  is  usually  clean  and  the 
appetite  increased  rather  than  diminished.  Acidity  is  common.  A  s 
a  result,  atony  of  the  muscular  coat  takes  place,  followed  by  gastrec- 
tasis.  The  neurosis  is  then  converted  into  an  organic  lesion,  and  the 
symptoms  of  dilatation  arise. 

JReichman's  Disease  is  a  hypersecretion  of  the  gastric  juice,  and 
there  are  two  forms — the  acute,  which  is  generally  of  nervous  origin, 
and  the  chronic.  The  latter  is  seen  in  emaciated  persons;  the  stomach 
is  dilated,  and  succussion- splash  is  readily  obtained.  The  diagnosis 
is  made  in  part  by  examination  of  the  gastric  contents,  which  are  re- 
moved five  to  six  hours  after  the  meal.  The  quantity  will  be  found 
large.  On  standing,  the  material  becomes  separated  into  three  layers 
— an  upper,  frothy  layer;  a  middle,  turbid,  yellowish  layer,  and  a 
lower,    consisting  of    starchy   matter.      In   order    to   determine   that 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     553 

hypersecretion  exists,  the  stomach-conteuts  are  removed  in  the 
evening,  and  the  viscus  washed  out  thoroughly  until  the  water  is  no 
longer  acid  in  reaction.  The  patient  receives  no  food  until  the  next 
morning,  when,  after  the  proper  interval,  the  contents  of  the  stomach 
are  again  evacuated.  From  30  to  600  c.c.  (1  to  19  ounces)  of  fluid 
will  now  be  obtained,  which,  on  examination,  proves  to  be  active 
gastric  juice.      The  disease  is  chronic. 

In  order  to  make  a  diagnosis  the  secretions  must  be  secured  while 
fasting.  The  patients  usually  improve  on  albuminous  food,  which 
differentiates  it  from  gastralgia  and  pyrosis  of  acid  fermentation. 
Alkalies  give  temporary  relief. 

Gastroxynsis  is  a  gastric  neurosis  in  which,  after  mental  overexer- 
tion or  profound  emotional  disturbance,  there  is  sudden  vomiting  of 
acid  fluid,  continuing  for  a  considerable  time.  It  is  closely  allied  to 
migraine.  Xervous  belching  and  eructations  are  phenomena  of  the 
gastric  neuroses  of  motor  origin.  They  usually  occur  in  hysterical 
subjects  rather  than  in  neurasthenics.  In  the  latter  they  are  associated 
with  other  sensations,  particularly  oppression  and  tension  in  the  epigas- 
trium. In  hysteria  they  occur  alone.  There  is  increase  in  the  con- 
tractility of  the  stomach,  the  pyloric  sphincter  contracts  powerfully, 
and  the  stomach  is  distended;  gas  is  expelled  at  the  cardiac  end  of  the 
stomach.  They  may  be  due  to  paralysis  of  the  cardiac  end  of  the 
stomach  rather  than  to  contraction  of  the  pyloric  end.  They  occur 
involuntarily  generally.  They  must  not  be  confounded  with  the  pseudo- 
hysterical  vomiting  which  Bristowe  has  described.  In  the  latter 
instance  the  gas  is  raised  from  the  oesophagus  by  contraction  of  the 
muscles  of  the  neck.  Hysterical  eructation  is  very  freemen tly  of 
oesophageal  origin.  The  belching  is  loud  and  may  occur  in  paroxysms. 
The  gas  is  odorless,  and  hence  is  distinguisheel  from  the  gas  of  dys- 
pepsia and  fermentation  ;  it  is  in  all  probability  the  result  of  the 
swallowing  of  air. 

Pyrosis,  heartburn,  is  the  raising  of  sour  masses  from  the  stomach. 
The  stomach-contents  are  not  necessarily  hyperacid.  If  acid,  as  in 
the  normal  gastric  juice,  or  hyperacid,  the  regurgitation  causes  severe 
acrid  and  burning  sensations.  It  is  probably  due  to  heightened  con- 
tractility of  the  muscular  coat  of  the  stomach  with  pyloric  contraction, 
which  overcomes  the  weaker  cardia. 

Pneuma "ptosis.  Excess  of  gas  in  the  stomach.  When  the  stomach 
is  ovcrdistended  the  diaphragm  is  pushed  up,  pressing  on  the  heart. 
The  patients  are  seized  with  severe  dyspnoea.  At  first  inspiration  is 
difficult,  and  finally  both  inspiration  and  expiration  become  difficult. 
Palpitation  of  the  heart  and  pulsation  of  the  peripheral  arteries  take 
place.  There  is  fulness  of  the  head  and  a  sensation  of  impending 
death.  The  patient  may  become  unconscious.  Relief  can  only  he 
afforded  by  belching,  when  the  attack  rapidly  subsides.  Introducing 
a  stomach  bougie  gives  immediate  relief. 

\i  rcous  Vomiting  (sec  Subjective  Symptoms  and  Gastroxynsis). 

Peristaltic  Unrest.  Characterized  by  borborygmi  and  gurgling,  which 
begin  immmediately  after- eating,  are  heard  at  a  considerable  distance, 


554  SPECIAL  DIAGNOSIS. 

and  are  a  source  of  great  annoyance.     It  is  a  common  symptom  of  the 
gastric  neuroses. 

Rumination  (Merycismus).  Rumination  is  a  rare  condition  in  which 
the  patients  regurgitate  and  chew  the  cud  like  ruminants. 

Conditions  of  Depression.  In  conditions  of  depression  "poly- 
phagia, or  the  want  of  a  feeling  of  satiation  occurs;  if  gluttony  is 
excluded,  it  is  a  morbid  condition  of  extreme  rarity. 

Anacidity  of  the  gastric  juice  as  a  neurosis  is  found  in  hysterical  per- 
sons and  in  neurasthenics  (see  Absence  of  Hydrochloric  Acid). 

Relaxation  of  the  Cardiac  and  Pyloric  Ends  of  the  Stomach  from 
Conditions  Resembling  Paralysis.  When  the  cardiac  end  is  relaxed 
eructations  and  regurgitations  occur.  If  large  quantities  of  the  ma- 
terial from  the  stomach  are  regurgitated  and  expectorated,  the  condition 
is  pathological.  It  may  lead  to  serious  changes  in  nutrition.  It  may 
exist  for  years  without  bad  results.  It  must  not  be  confounded  with 
the  regurgitation  fn.m  diverticula  of  the  oesophagus.  In  the  latter 
regurgitation  is  produced  at  will. 

Atony,  or  Atonic  Dyspepsia.  It  accompanies  gastritis;  it  also  occurs 
as  a  primary  neurosis.  The  innervation  of  the  nerve-centres  regulating 
peristalsis  is  disordered.  The  primary  disorder  may  be  local  or  central. 
The  movement  of  the  chyme  is  tardy  or  insufficient.  Atony  should 
be  applied  to  the  disease  of  the  motor  function  only,  or,  as  Rosenbach 
states  it,  to  insufficiency  of  the  stomach.  The  symptoms  develop  grad- 
ually. At  first  occurs  oppression  during  digestion,  with  swelling  and 
fulness  of  the  stomach.  There  is  mental  and  physical  torpor  during 
the  time  of  the  digestive  act.  The  symptoms  become  aggravated,  and 
eructations  occur,  vomiting  begins,  and  gradually  the  fermentative 
symptoms  become  most .  pronounced.  At  this  period  it  is  putrid,  or 
fermentative  dyspepsia  By  the  usual  tests  the  motor  power  of  the 
stomach  is  found  to  be  diminished      The  secretions  are  also  scanty. 

Nervous  Dyspepsia.  According  to  Ewald,  this  is  the  true  gastric  neu- 
rasthenia, which  combines  all  forms  of  gastric  neuroses.  The  clinical 
picture  is  made  up  of  a  combination  of  all  the  neurosal  symptoms  men- 
tioned. Leube  considers  nervous  dyspepsia  a  group  of  symptoms  of  a 
cerebral  nature  due  to  abnormal  irritability  of  the  sensory  nerves  of  the 
stomach  during  the  normal  digestive  processes,  the  symptoms  of  which 
are  hypersesthesia  and  nausea,  hyperorexia,  anorexia,  parorexia,  and 
gastralgia.  Leube  thinks  the  true  peptic  activity  of  the  stomach  is 
unchanged.  While  the  anatomical  or  physiological  explanation  of  the 
condition  is  difficult,  the  clinical  symptoms  are  those  of  irritation  or 
paralysis,  the  manifestations  of  which  are  intermingled,  sometimes  one 
and  sometimes  another  being  most  prominent  (see  table,  page  548). 

The  one  characteristic  feature  is  that  the  symptoms  are  mild.  With 
severe  forms  of  gastralgia  nervous  vomiting  and  boulimia  do  not  occur. 
Symptoms  of  intestinal  indigestion  are  usually  associated  in  a  mild 
degree.  Constipation  is  of  the  most  common  occurrence,  although  in 
some  cases  there  is  diarrhoea.  In  other  cases  the  intestinal  indigestion 
is  much  aggravated  with  mild  gastric  disturbances  and  anorexia,  repug- 
nance toward  taking  food,  furred  tongue  and  mild  nausea,  constipation 
and  colicky  pain,  either  diffuse  or  in  separate  painful  spots.      The  abdo- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     555 

men  is  distended  and  tympanitic,  sometimes  to  a  marked  degree.  It 
is  called  flatulent  dyspepsia.  Along  with  the  gastric  and  intestinal 
symptoms,  the  general  nervous  symptoms  to  which  the  term  neurasthe- 
nia is  applied  are  present.  These  nervous  manifestations  sometimes 
precede  the  local  gastric  symptoms,  but  as  the  latter  develop  the  former 
become  more  aggravated.  The  dyspeptic  conditions,  as  Ewald  puts 
it,  are  on  a  neurotic  basis,  or  such  as  may  occur  as  reflex  neuroses  in 
chlorosis,  menstrual  disorders,  uterine  and  ovarian  disease,  and  intense 
physical  excitement.  As  far  as  we  know  there  are  no  great  alterations 
in  the  chemical  functions  when  anatomical  and  pathological  changes 
are  absent.  An  indigestion  of  short  duration,  a  mild  catarrh,  recurring 
hyperemia,  have  been  the  primary  causes  of  nervous  symptoms  in  the 
digestive  organs. 

Diagnosis.  There  are  no  characteristic  symptoms,  and  the  student 
must  bear  in  mind  that  it  may  be  necessary  to  make  several  examina- 
tions and  listen  to  the  story  of  the  subjective  symptoms  frequently 
before  a  conclusion  can  be  arrived  at.  This  is  all  the  more  necessary 
because  of  the  frequency  of  organic  lesions  and  neurasthenic  conditions 
being  present  at  the  same  time.  The  course  of  the  disease  must  be 
observed  for  a  long  time,  all  possible  causal  factors  investigated,  and 
all  the  general  signs  of  neurasthenia  carefully  considered.  In  addition 
it  may  be  necessary  to  use  therapeutic  tests.  If  the  possible  organic 
diseases  are  not  relieved  by  such  measures,  there  must  be  a  deeper  basis 
for  the  gastric  symptoms.  Just  as  in  neurasthenia  and  in  neurasthenic 
states  elsewhere,  the  individual  must  be  considered  as  to  peculiarities, 
idiosyncrasies,  and  all  his  relations  in  life,  in  connection  with  the  gen- 
eral and  local  symptoms  of  the  neurasthenic  state.  Great  stress  must 
be  placed  upon  the  study  of  individual  symptoms,  their  mutual  rela- 
tionship, and  their  changeable  occurrence.  In  gastric  neurasthenia  gas- 
tralgia  is  more  diffuse  than  the  pain  of  ulcer  or  cancer  of  the  stomach. 
It  is  not  so  much  dependent  upon  food  as  either  of  the  others,  partic- 
ularly ulceration.  In  gastric  neurasthenia  vomiting  is  rare.  The  vom- 
it us  is  composed  of  mucus  mixed  with  bile  and  food  in  various  stages 
of  digestion.  It  is  never  bloody  nor  does  it  contain  decomposed  masses. 
Hysterical  vomiting  occurs  with  ease  and  regularity  compared  with  the 
vomiting  of  neurasthenia.  The  vomiting  in  neurasthenia  is  bitter,  due 
to  the  pre-ence  of  peptones.  In  gastric  neurasthenia  the  stools  arc 
changeable  in  character.  They  do  not  contain  undigested  remnants 
of  food,  or  mucus,  or  blood.      The  form  of  the  fseces  is  variable. 

Differential  Diagnosis.  Neoplasms,  ulcers,  strictures,  dilatation 
are  distinguished  by  physical  signs  or  characteristic  symptoms.  In 
gastric  neurasthenia  the  stomach  should  be  empty  seven  hours  after 
taking  a  meal.  The  results  of  the  chemical  examination  are  not  suffi- 
ciently definite  for  diagnostic  purposes,  for  at  times  the  same  chemical 
changes  are  present,  as  in  ulcer,  carcinoma,  and  chronic  catarrh.  The 
diagnosis  must  be  based  largely,  as  previously  intimated,  upon  pro- 
longed observation  and  a  carefully  taken  history,  and  upon  the  general 
condition  of  the  patient.  The  cases  must  not  be  mistaken  for  costal 
neuralgia,  although  it  is  not  usually  easy  to  be  led  astray.  Reflex  gas- 
trie   neuroses  are   seen,  as   indigestion,  gastralgia,  or   vomiting.      The 


556  SPECIAL  DIAGNOSIS. 

types  are  interchangeable,  although  vomiting  occurs  in  the  more  acute 
reflexes,  indigestion  in  the  more  chronic.  The  cerebral  disorders  which 
give  rise  to  vomiting  are  meningitis,  abscess,  and  tumor.  The  vomit- 
ing may  be  transitory,  or  may  be  persistent.  There  is  usually  hyper- 
secretion of  the  gastric  juice.  The  vomiting  may  usher  in  the  disease 
or  develop  during  its  course.  If  vomiting  is  of  long  standing,  its  pos- 
sibly reflex  origin  should  always  be  investigated  (see  Vomiting). 

Gastralgia  is  sometimes  a  reflex  from  lesions  in  the  cervical  and 
dorsal  portions  of  the  cord;  not  only  in  the  posterior  columns,  but  also 
in  disseminated  sclerosis.  Vomiting  occurs,  and  the  attack  is  known 
as  a  gastric  crisis. 

Chronic  dyspepsia  is  a  frequent  reflex  disorder  of  diseases  of  the 
sexual  organs,  as  amenorrhoea  and  dysmenorrhoea,  in  the  climacteric 
period,  and  in  chronic  inflammations  of  the  uterus.  In  malpositions 
and  tumors,  and  in  pelvic  exudations  with  traction,  in  ulcers,  in  ova- 
rian tumors,  the  so-called  dyspepsia  uterina  of  Kisch  is  common. 

The  Stomach  in  Other  Diseases.  Diseases  of  the  stomach  may 
frequently  mask  other  diseases;  in  other  words,  patients  will  complain 
of  gastric  symptoms  which  are  but  concomitant  phenomena,  behind 
which  there  are  graver  conditions.  Thus,  in  disease  of  the  kidney, 
in  phthisis,  in  chronic  gastritis,  in  emphysema,  in  valvular  disease  of 
the  heart,  catarrh  of  the  mucous  membrane  of  the  stomach  is  of  fre- 
quent occurrence,  depending  upon  the  primary  disease.  In  tuberculosis- 
the  local  gastric  symptoms  often  seem  to  be  more  prominent  features. 
Thus,  in  the  earlier  stages  of  phthisis  loss  of  appetite  and  vomiting 
are  of  constant  occurrence.  The  dyspeptic  symptoms  in  a  large  number 
of  cases  precede  the  pulmonary  symptoms  and  may  be  so  pronounced  as 
to  mask  them  entirely.  The  patients  are  usually  delicate  and  anaemic  ; 
they  complain  of  loss  of  appetite  and  mild  indigestion  ;  there  is  some 
regurgitation  of  food  ;  they  are  feeble  and  languid  ;  they  are  treated 
for  chronic  catarrhal  gastritis,  but  do  not  improve.  On  examination 
of  the  lungs  the  physician  is  surprised  to  find  a  small  area  of  consoli- 
dation, and  upon  inquiry  will  find  subjective  symptoms  of  tuberculosis 
to  have  been  present  for  a  considerable  time.  Every  practitioner  is 
familiar  with  the  scores  of  patients  with  phthisis,  which  may  even  be 
advanced,  who  believe  that  their  symptoms  are  entirely  due  to  disorder 
of  the  stomach.  In  addition  to  the  early  catarrh  that  precedes  tuber- 
culosis, other  gastric  symptoms  may  occur.  The  well-known  associa- 
tion of  ulcer  in  phthisis  is  familiar  ;  although  there  is  probably  no 
causal  relation,  and  the  association  is  purely  accidental,  because  both 
occur  at  the  same  time  of  life,  yet  the  gastric  symptoms  may  prevent 
investigation  into  those  of  pulmonary  origin.  In  ancemia  and  chlorosis 
the  changes  in  the  digestive  tract  are  common.  On  account  of  the 
general  blood-condition  the  functions  "of  the  stomach  are  impaired. 
Here,  too,  we  frequently  have  the  association  of  ulcer  with  the  general 
condition.  Danger  of  overlooking  either  is  not  so  great  as  in  tuber- 
culosis. 

Valvular  Affections  of  the  Heart.  Chronic  catarrh  of  the  stomach 
may  result  from  venous  congestion  ;  the  symptoms  may  point  to  the 
gastric  condition  alone.      In  all  cases  of  chronic  gastric  catarrh  it  is. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     557 

necessary  to  examine  carefully  into  the  condition  of  the  heart.  Over 
and  over  again  patients  apply  for  treatment  not  on  account  of  cardiac 
symptoms,  but  because  of  gastric  disorder.  They  will  be  treated  in 
vain  unless  the  primary  affection  is  ascertained.  Many  cases  of  gastric 
catarrh  have  been  cured  by  the  use  of  digitalis.  In  disease  of  the 
kidneys  the  stomach  is  frequently  involved.  Vomiting  and  other 
symptoms  of  gastric  indigestion  may  occur  long  before  dropsy  or  any 
objective  sign  which  would  lead  to  a  correct  diagnosis.  The  gastric 
symptoms  are  due  to  chronic  uraemia.  In  other  conditions  of  the 
genito-urinary  tract  gastric  symptoms  also  occur.  This  is  particularly 
noticeable  in  long-standing  retention  from  chronic  obstruction.  Renal 
tumors  may  cause  only  disturbances  of  digestion,  while  gastric  symp- 
toms due  to  movable  kidney  are  well  known.  The  symptoms  in  the 
latter  condition  arise,  first,  from  mechanical  causes,  as  the  pressure  of 
the  kidney  on  the  pylorus,  and,  secondly,  from  the  influence  on  the 
nervous  system. 

Disease  of  the  Liver.  The  intimate  relationship  of  the  liver  and  the 
stomach  is  such  that  when  one  is  the  seat  of  serious  functional  disturb- 
ance the  other  is  likely  to  be  affected.  Frequently  it  is  impossible  to 
draw  fast  lines  as  to  which  organ  is  the  primary  seat  of  disorder.  The 
abuse  of  alcohol  frequently  induces  chronic  gastritis  and  this  intoxicant 
also  causes  cirrhosis  of  the  liver.  On  the  other  hand,  cirrhosis  of  the 
liver  is  frequently  accompanied  by  chronic  gastritis  secondary  to  a 
portal  congestion. 

Diseases  of  the  Central  Nervous  System.  The  relationship  of  disease 
of  the  central  nervous  system  to  those  of  the  stomach  has  frequently 
been  adverted  to  (see  Vomiting).  In  sclerosis  of  the  posterior  col- 
umns of  the  cord  this  is  more  striking  than  in  any  other  condition. 
Not  only  do  we  have  gastralgia  and  gastric  crises,  but  moderate  symp- 
toms of  indigestion,  with  hyperesthesia  and  slight  gastralgia,  may  be 
the  first  symptoms  of  lumbar  ataxia. 

Diabetes.  Diabetes  may  continue  (in  its  course)  for  a  long  period  of 
time,  during  which  the  patient  is  thought  to  have  stomach-trouble, 
before  an  examination  of  the  urine  reveals  the  true  nature  of  the  case. 
In  gout  and  the  rheumatic  diathesis  opinions  differ  as  to  the  relationship 
of  the  stomach  to  this  disorder.  Some  writers  are  full  of  the  belief 
that  a  specific  gouty  inflammation  of  the  stomach,  due  to  the  uric-acid 
diathesis,  is  of  frequent  occurrence,  and  that  one  of  the  prominent 
manifestations  of  gout  is  dyspepsia  in  all  its  forms.  The  French  con- 
sider gastric  disturbances  to  be  frequent  expressions  of  the  rheumatic 
diathesis.  The  relationship  of  the  two,  however,  is  thus  far  not  fully 
developed,  although,  in  these  conditions,  it  is  not  usual  to  overlook 
the  presence  of  either  of  the  diatheses  when  symptoms  of  gastric  dis- 
turbances occur.  It  is  essential  to  bear  in  mind'  that  in  persons  of  a 
rheumatic  or  gouty  diathesis  gastric  disturbances  are  likely  to  occur  as 
in  healthy  individuals;  their  successful  management  depends  upon  the 
recognition  of  the  fundamental  diathesis. 


558  SPECIAL  DIAGNOSIS. 


Diseases  of  the  Intestines. 

The  intestine  is  a  canal  of  varying  dimensions,  the  physiological  office 
of  which  is  to  propel  material  received  from  the  stomach,  and  to 
permit  of  the  digestion  and  absorption  of  that  which  is  to  serve  for 
the  nutrition  of  the  body.  The  canal  is  richly  supplied  with  blood- 
vessels and  lymphatics.  It  is  made  up  of  mucous  membrane,  muscle, 
and  peritoneum.  For  the  purpose  of  digestion,  fluids  are  secreted, 
either  from  the  intestinal  glands  or  large  neighboring  glands  which 
discharge  into  the  canal. 

Diseases  which  affect  the  canal  impair  or  cause  an  abeyance  of  the 
physiological  offices.  As  these  offices — absorption  and  digestion — are 
essential  to  nutrition,  it  is  not  surprising  that  the  body- weight  and 
strength  are  impaired.  We  know  too  little  about  the  function  of 
digestion  to  utilize  such  knowledge  in  diagnosis.  Intestinal  digestion 
is  also  dependent  upon  the  healthy  performance  of  the  functions  of  the 
liver  and  pancreas.  It  is  difficult  to  draw  fine  lines  of  distinction  even 
in  health,  and  intestinal  pathology  is  closely  interwoven  with  hepatic 
and  pancreatic  pathology. 

Alterations  of  the  function  of  the  intestine  as  a  canal  give  rise  to 
distinctive  symptoms.  Either  its  movements  are  too  frequent  -and 
•  rapid,  causing  diarrhoea,  or  too  sluggish,  causing  constipation.  Obstruc- 
tion of  the  canal  leads  to  symptoms  common  to  such  a  condition  (see 
Morbid  Process),  modified  by  the  physiological  duties  and  the  ana- 
tomical structure  of  the  canal. 

The  morbid  processes  are  hypersemias,  inflammations,  degenerations, 
and  new  growths.  The  symptoms  that  attend  these  processes  are  not 
different  from  the  symptoms  that  attend  such  processes  in  similar  struc- 
tures elsewhere.  It  must  not  be  forgotten  that  the  function  of  the 
canal  is  influenced  by  each  process.  On  account  of  the  process  we 
may  have  pain  and  fever  ;  on  account  of  the  impaired  function,  pain, 
flatulency,  diarrhoea  or  constipation,  change  in  the  character  of  the  stools, 
and  impaired  nutrition.  Some  of  the  above  morbid  processes  may  lead 
to  the  mechanical  condition,  obstruction. 

The  morbid  alterations  of  the  intestinal  tract  are  ascertained  by  data 
obtained  by  inquiry  and  by  observation.  The  data  obtained  by  inquiry 
include  the  subjective  symptoms — pain,  and  discomfort  from  flatulency. 
By  observation  the  general  condition  of  the  patient,  the  presence  of 
tenderness,  alterations  in  the  size  and  shape  of  the  abdomen,  and  other 
physical  phenomena  are  observed.  The  freces  are  carefully  studied, 
with  the  object  of  determining  modifications  of  the  function  of  the 
bowel,  the  presence  of  ingredients  due  to  some  morbid  process,  as 
serum,  blood,  pus,  or  mucus,  or  of  extraneous  matter,  as  worms  or 
foreign  substances.  The  faeces  are  studied  by  the  naked  eye,  by  the 
microscope,  and  by  bacteriological  methods. 

One  symptom  may  be  the  chief  manifestation  of  a  disease,  as  pain 
of  lead-colic,  diarrhoea  of  several  morbid  disorders,  constipation  of 
others.  In  the  discussion  of  the  special  symptoms  a  consideration  of 
the  diseases  of  which  the  symptom  is  the  main  expression  will  be 
taken  up. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     559 

The  intestine  is  the  recipient  of  material  for  nutrition,  which  may 
contain  parasitic  forms  of  animal  life  or  their  ova  or  spores,  which 
enter  the  body  in  this  manner.  They  remain  in  the  intestinal  tract  or 
wander  into  other  structures.  They  include  animal  and  vegetable  par- 
asites. To  the  class  of  parasites  belong  forms  of  protozoa,  vermes, 
and  fungi.  While  the  canal  is  open  to  infection  by  various  micro- 
organisms, it  is  the  natural  habitat  of  others  which  may  become  dele- 
terious agencies  when  the  conditions  of  their  environment  are  changed. 
Thus  the  bacillus  coli  communis  is,  in  man,  with  normal  epithelial 
structure  and  normal  secretions,  an  innocuous  parasite  which,  when 
inflammation  sets  in,  may  become  nocuous. 

The  symptoms  of  the  protozoa  and  fungi,  or  of  their  products,  the 
ptomaines,  are  of  an  infectious  or  toxic  nature.  Inflammation  is  pro- 
duced locally,  while  general  infective  or  toxic  symptoms  occur. 

The  symptoms  of  worms,  if  retained  in  the  intestinal  canal,  are  : 
(1)  Reflex  in  nature  ;  (2)  symptoms  due  to  catarrhal   inflammation  ; 

(3)  symptoms  due  to  action  of  the  parasite  on  the  blood — anaemia  ; 

(4)  symptoms  due  to  wandering  of  the  parasite,  as  in  trichinosis  (see 
Faeces). 

Symptoms  of  the  Tcenice  and  Bothriocephalic  There  may  be  no  symp- 
toms save  discharge  of  the  parasite  or  portions  of  it  by  the  rectum.  In 
others  the  symptoms  of  intestinal  dyspepsia  or  intestinal  catarrh  are 
observed.  Headache,  giddiness,  lassitude,  and  itching  at  the  nose  and 
at  the  anus  are  said  to  be  present.  The  patient  becomes  hypochon- 
driacal. Convulsive  disorders  occur.  Hysteria,  forms  of  epilepsy, 
grinding  of  the  teeth  at  night,  and  restlessness  attend  the  habitation 
of  the  parasite  in  the  intestine.  In  all  convulsive  disorders  the  pos- 
sibility of  worms  as  a  cause  must  be  remembered. 

Symptoms  of  Ascarides.  (1)  Gastro-intestinal  catarrh;  (2)  symptoms 
of  obstruction  (rare);  (3)  symptoms  due  to  wandering — as  to  the  hepatic 
duct  or  to  the  stomach,  to  the  vagina;  (4)  nervous  symptoms  of  reflex 
origin  ;  (5)  the  worm  or  its  ova  in  the  feces. 

Symptoms  of  Oxyuris  Vermicularis.  (1)  Gastro-intestinal  dyspepsia 
or  catarrh  ;  (2)  itching  or  heat  at  the  anus,  worse  in  bed ;  (3)  vesical 
and  rectal  tenesmus  ;  (4)  erythema  about  the  anus  ;  (5)  priapism  ;  (0) 
vulvitis  and  vaginitis  ;  (7)  the  worms  in  the  faeces. 

The  Strongylus.  The  symptoms  are  local,  with  the  symptoms  of 
profound  anaemia.  The  discovery  of  the  ova.in  the  faeces  distinguishes 
this  form  of  anaemia  from  other  varieties. 

The  symptoms  due  to  the  presence  of  the  trichina  spiralis  and  filaria 
will  be  discussed  in  appropriate  sections  (see  Blood  and  General  Dis- 
eases). 

The  Intestines  in  other  Diseases.  The  relationship  of  intestinal  dis- 
orders to  affections  of  other  viscera  will  be  discussed  with  each  symp- 
tom. It  must  not  be  forgotten  that  derangement  of  this  trad  may 
have  its  origin  in  local  causes  or  in  causes  remote  from  the  intestinal 
tract,  or  in  some  general  condition  of  the  individual.  Thus  diarrhoea 
may  be  due  to  inflammation  which  is  primarily  local,  or  wliieh  may  lie 
secondary  to  infection.  Nothing  is  more  common  than  to  see  diarrhoea 
with  general  infection,   as  septicaemia.      In  exophthalmic  goitre   the 


560  SPECIAL  DIAGNOSIS. 

diarrhoea  is  not  due  to  a  local  cause,  but  to  some  as  yet  unknown  nerve 
disorder.  Constipation  inay  be  due  to  central  brain  disease,  to  a  gen- 
eral condition  like  diabetes,  or  be  of  local  origin. 

It  must  be  remembered  that  the  diagnosis  of  an  intestinal  lesion  is 
never  complete  without  determining  its  causes.  Thus  enteritis  and 
ulceration  occur  in  typhoid  fever,  in  cholera,  and  in  other  infectious 
disorders,  all  of  which  are  to  be  passed  in  review  in  making  up  a  diag- 
nosis. Diarrhoea  is  a  symptom  in  Bright' s  disease,  and  the  causal 
relationship  must  always  be  borne  in  mind. 

Intestinal  diseases  or  disorders  are  not  usually  confounded  with  dis- 
ease of  other  structures.  It  is  worthy  of  remark,  as  a  fact  which  is 
sometimes  overlooked,  that  symptoms  of  intestinal  obstruction  are  fre- 
quently due  to  peritonitis.  Tumors  of  the  intestine  must  be  distin- 
guished from  tumors  of  the  peritoneum,  the  stomach,  pancreas,  and 
liver,  and  the  uterus  and  ovaries.  The  history,  the  seat  and  physical 
character  of  the  tumor,  and  the  associate  symptoms,  point  to  the  true 
condition. 

Arteries  of  the  Intestine.  The  intestines  are  supplied  by  the  mesen- 
teric arteries.  Its  branches  may  become  the  seat  of  emboli.  The 
symptoms  are  sudden  pain,  intestinal  hemorrhage,  and  discharge  of  a 
portion  of  intestine.  The  patients  are  the  subjects  of  atheroma  or 
heart  disease. 

The  Data  Obtained  by  Inquiry.     The  Subjective  Symptoms. 

Pain.  Colic.  Colic  is  the  term  applied  to  paroxysmal  pain  in  the 
abdomen.  It  is  characterized  by  suddenness  of  onset  and  by  alteration 
of  intestinal  function.  It  attends  all  forms  of  inflammation  of  the 
intestinal  tract.  It  is  applied  to  a  peculiar  affection  known  as  lead- 
colic,  due  to  local  effects  of  lead.  The  term  colic  is  also  applied  tc 
painful  affections  of  the  hepatic  ducts,  pancreatic  ducts,  the  ureters, 
and  the  uterus.  Intestinal  colic  is  the  form  at  present  referred  to. 
In  addition  to  the  inflammations  of  the  intestinal  tract  it  may  be  due 
to  indigestion  with  flatulency.  When  it  occurs  suddenly  without  local 
cause  it  is  known  as  enteralgia.     It  is  a  nervous  affection. 

Intestinal  Colic.  The  colic  of  intestinal  indigestion  occurs  suddenly, 
or  may  be  preceded  by  signs  of  intestinal  indigestion.  The  pain  is 
chiefly  in  the  umbilical  region  and  radiates  from  that  point.  It  is 
relieved  by  moderate  pressure  or  warmth.  The  patient  is  restless  and 
irritable.  The  face  is  anxious.  The  pain  causes  him  to  roll  about 
and  double  up.  There  is  a  cold  sweat,  and  the  pulse  is  small  and  hard. 
Nausea  and  vomiting  follow  the  pain,  and  there  are  gaseous  eructations. 
The  abdomen  is  distended  with  gas,  and  tympanitic  on  percussion. 
Prostration  or  collapse  rapidly  ensues,.  The  pain  may  be  relieved  by 
the  passing  of  flatus.  With  the  local  pain  there  is  spasm  of  the  mus- 
cles of  the  calves.  The  cramps  are  very  painful  ;  the  muscles  become 
knotted.  The  hands  and  feet  are  also  cramped.  The  pain  is  said  to 
be  due  to  spasm  of  the  intestine,  and  is  known  also  as  spasmodic  colic. 
It  is  certainly  due  to  distention  or  to  irritation. 

If  the  intestinal  colic  is  due  to  indigestible  food,  it  may  have  been 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     561 

preceded  by  an  attack  of  acute  indigestion,  and  the  griping  pains  may 
have  developed  at  long  intervals,  with  gastric  and  intestinal  flatulency. 
Vomiting  may  precede  or  attend  the  attack,  and  diarrhoea  follow.  If 
the  colic  is  due  to  gas  alone,  there  is  great  tympanites.  If  it  is  due  to 
fceces,  it  has  been  preceded  by  a  history  of  constipation,  and  there  may 
be  faecal  masses  detected  in  the  rectum  or  along;  the  colon. 

Diagnosis.  The  sudden  severe  pain,  often  relieved  on  the  discharge 
of  gas,  with  gastro-intestinal  disorder,  tympanites,  the  occurrence  of 
cramps  in  the  extremities,  and  the  localization  of  pain  to  the  umbilicus, 
all  point  to  the  true  nature  of  the  affection.  A  history  of  indiscretion 
in  diet,  or  exposure,  aids  in  the  diagnosis.  In  colic  the  pain  may  come 
on  suddenly,  or  increase  gradually  from  a  sense  of  discomfort  or  sore- 
ness. The  pain  at  its  height  is  described  as  agonizing,  and  of  a  boring 
or  shooting  character,  abating  for  a  time  and  then  increasing  until  the 
patient  rolls  and  twists  in  agony  and  breaks  out  into  a  cold  sweat.  The 
pain  may  shoot  from  the  seat  of  greatest  intensity  to  the  shoulders, 
back,  chest,  or  iliac  region. 

It  must  be  distinguished  from  enteraJgia.  The  latter  comes  on 
slowly  and  lasts  for  hours  or  days.  The  pain  is  situated  around  the 
umbilicus,  and  is  relieved  by  deep  pressure,  although  the  skin  may  be 
hypersesthetic.  Sometimes  the  abdomen  is  retracted  ;  there  are  no 
signs  of  indigestion,  and  flatulency  and  borborygmi  are  absent. 

Lead-colic.  If  the  enteralgia  is  due  to  lead,  there  is  a  history  of  ex- 
posure to  that  metal.  The  blue-line  on  the  gums,  with  obstinate  con- 
stipation but  no  vomiting,  and  the  occurrence  of  neuritis  due  to  satur- 
nine-poisoning, point  to  the  true  nature  of  the  case. 

Hepatic  Colic.  In  hepatic  colic  the  pain  is  situated  in  the  region  of 
the  liver  and  may  radiate  to  the  shoulder  or  back.  It  is  sometimes 
fixed  in  the  right  parasternal  line  about  the  cartilages  of  the  sixth 
and  seventh  ribs.  The  attack  is  attended  by  vomiting,  usually  of 
bilious  fluid.  It  occurs  in  women  most  frequently;  the  patients  are 
almost  always  over  forty  years  of  age.  It  may  be  followed  by  jaun- 
dice. There  is  local  tenderness,  and  there  may  be  some  swelling  in 
the  region  previously  mentioned.  The  bowels  are  constipated,  and 
after  the  attack  may  contain  gallstones. 

Renal  Colic.  In  renal  colic  pain  begins  in  the  kidney  and  then 
extends  along  the  ureter.  It  is  always  more  localized  to  the  right  or 
left  of  the  median  line  in  the  abdomen.  It  is  more  frequently  in  the 
lower  portion  of  either  of  the  upper  quadrants,  three  inches  to  either 
side  of  the  median  line,  depending  upon  the  kidney  affected.  From 
this  region  the  point  of  maximum  intensity  and  of  local  tenderness 
moves  to  the  lower  quadrant  toward  the  median  line  in  the  oblique 
direction,  rarely  getting  an  inch  below  the  transverse  umbilical  line. 
The  pain  then  extends  to  the  region  above  the  pubes  and  down  the 
thighs.  From  the  first  there  is  increased  frequency  of  micturition. 
The  urine  is  scanty,  high-colored,  and  may  contain  blood.  With  the 
five  micturition  relief  follows. 

Local  Peritonitis.  Pain  connected  with  the  liver,  spleen,  and  kid- 
neys is  generally  due  to  involvement  of  the  peritoneal  coverings  of 
these  organs,  and  partakes  of  the  character  of  local  peritonitis.     It 

36 


562  SPECIAL  DIAGNOSIS. 

may,  however,  be  due  to  malignant,  ulcerative,  or  inflammatory  disease, 
and  the  diagnosis  must  be  made  by  noting  the  character  of  the  pain, 
its  intensity,  duration,  seat,  and  the  other  general  and  local  symptoms 
with  which  it  is  associated. 

Rectal  Pain.  Pain  in  defgecation  may  be  due  to  piles,  internal  or 
external,  or  to  fissure,  or  may  be  the  result  simply  of  the  passage  of 
an  unusually  large,  hard  mass.  Pain  from  fissure  is  most  acute  and 
spasmodic,  and  persists  for  some  time  after  defeecation.  Fibroid  stric- 
ture of  the  rectum  causes  more  pressure  and  straining  at  stool  than 
real  pain;  but  cancer  is  apt  to  be  extremely  painful. 

Uterine  Colic.  In  uterine  colic  the  pain  is  situated  in  the  pelvis. 
There  is  some  abnormality  of  discharge,  and  a  history  of  uterine  dis- 
ease. Care  must  be  taken  not  to  confound  the  sudden  pain  of  extra- 
uterine pregnancy  with  intestinal  colic  or  other  forms  of  abdominal 
pain.  In  extrauterine  pregnancy  the  pain  is  in  the  lower  quadrants  of 
the  abdomen  to  the  right  or  left  of  the  median  line.  It  is  sudden  and 
intense,  attended  by  more  or  less  collapse.  It  may  be  attended  by  all 
the  symptoms  of  internal  hemorrhage.  It  may  cause  vomiting.  The 
history  of  cessation  of  menses,  or  other  signs  of  pregnancy,  of  dis- 
charge of  decidua,  with  the  local  signs  on  physical  examination, 
indicate  the  true  nature  of  the  pain. 

Pancreatic  Pain.  In  disease  of  the  pancreas,  either  from  the  passage 
of  calculi  (extremely  rare)  or  because  of  pancreatic  hemorrhage,  there 
may  be  sudden  severe  pain.  The  pain  is  localized  to  the  region  below 
the  sternum.  It  may  be  severe  in  the  back  and  extend  up  the  thorax. 
It  occurs  in  paroxysms,  and  is  attended  by  great  anxiety  and  collapse. 

Gastric  Pain.  Intestinal  colic  must  be  differentiated  from  pain  of 
gastric  ulcer,  gastric  cancer,  and  gastralgia.  The  characteristics  of 
pain  in  these  affections  have  been  discussed.  When  perforation 
occurs  in  gastric  ulcer  the  pain  is  usually  seated  in  the  epigastrium, 
but  may  be  complained  of  in  the  back  as  high  as  the  mid-scapular 
region.  It  is  sudden  and  severe,  preceded  by  a  history  of  ulcer  and 
attended  by  collapse.  There  are  no  evidences  of  indigestion.  Per- 
foration of  the  biliary  passages  is  attended  by  pain  in  the  hepatic  region. 
The  pain  is  sudden  and  is  usually  preceded  by  symptoms  due  to  de- 
rangement of  the  biliary  passages  from  obstruction  by  gallstones. 

Appendicitis.  Intestinal  colic  must  not  be  confounded,  although  it 
frequently  has  been,  with  the  pains  that  attend  appendicitis.  This  is 
particularly  the  case  with  relapsing  appendicitis.  In  this  form  only 
mild  fever  attends  the  attack.  The  patient  is  seized  with  severe  pain, 
which  may  be  described  as  occurring  in  the  lower  right  quadrant,  but 
is  sometimes  complained  of  about  the  umbilicus.  It  frequently  fol- 
lows indiscretion  in  diet,  and  may  be  attended  by  vomiting,  and  is 
likewise  usually  relieved  by  eructation,  but  not  by  the  passage  of  gas, 
a  point  of  great  importance  in  the  diagnosis.  The  attack  occurs  mostly 
in  young  subjects  and  lasts  from  twelve  to  twenty-four  hours.  It 
may  be  so  severe  as  to  cause  collapse.  If  fever  attends  it,  and  there 
is  true  appendicitis,  the  diagnosis  is  much  easier.  In  the  relapsing 
as  well  as  the  true  form  there  is  tenderness  at  McBurney's  point  (see 
Appendicitis). 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     563 

Peritonitis.  Intestinal  colic  must  not  be  confounded  with  peritonitis, 
which  follows  in  all  the  above  conditions,  or  develops  at  various  points 
in  the  abdomen.  The  purulent  peritonitis  that  succeeds  pyosalpinx 
may  be  attended  by  severe  pain  without  much  reaction.  The  pain, 
however,  although  complained  of  about  the  umbilicus,  can  be  localized 
by  pressure  in  the  lower  quadrant  and  in  the  pelvis.  It  may  disap- 
pear after  eight  or  ten  hours,  to  be  followed  by  a  recurrence.  The 
recurrence  of  pain  is  usually  attended  by  fever.  In  the  first  twenty- 
four  hours  the  bowels  are  loose,  or  at  least  readily  moved.  If  the 
peritonitis  continues  beyond  this  period,  it  is  often  impossible  to  move 
the  bowels. 

Organic  Disease  of  the  Boioels.  Intestinal  colic  must  not  be  con- 
founded with  organic  disease  of  the  bowels  with  resulting  obstruc- 
tion. In  these  affections  there  are  sudden  constipation  and  rapid 
prostration.  The  vomiting,  if  present,  persists  and  soon  becomes  ster- 
coraceous.  In  intussusception  the  stools  are  characteristic.  Strangu- 
lation or  ileus  is  associated  with  the  presence  or  history  of  previous 
peritonitis  or  hernia.  In  the  latter  there  may  be  signs  at  the  hernial 
points.  In  the  obstruction  from  external  pressure  the  presence  of 
tumors  has  been  known  previously  or  can  be  recognized.  In  faecal 
obstruction,  or  the  obstruction  by  gallstones,  the  local  signs  may  be 
pronounced,  and  the  pain  is  usually  in  the  ileo-csecal  region.  The 
affection  is  acute.  Pain  that  extends  over  a  long  period  of  time,  that 
is  not  due  to  an  acute  process,  or  attended  by  severe  acute  symptoms, 
has  been  considered  elsewhere  (see  Abdomen). 

Abdominal  Rheumatism  and  Neuralgia.  Intestinal  colic  may  be 
mistaken  for  rheumatism  of  the  abdominal  walls.  In  the  latter  there 
may  be  a  history  of  exposure.  The  muscles  are  extremely  tender. 
There  are  no  gastro-intestinal  symptoms,  the  urine  is  loaded  with  uric 
acid  and  urates,  and  there  may  be  muscular  pain  in  other  situations, 
or  a  pronounced  history  of  previous  attacks  of  rheumatism.  In  lumbo- 
abdominal  neuralgia  the  pain  may  simulate  intestinal  colic.  Pressure- 
points  where  the  respective  nerves  have  their  exit  through  the  fascia 
are  detected. 

Just  here  may  be  considered  the  pain  about  the  navel,  which  occurs 
in  paroxysms,  due  to  disease  of  the  vertebrae.  There  may  be  caries 
from  tuberculous  disease  or  from  pressure  of  an  aneurism  or  malignant 
growths.     Examination  of  the  vertebrae  may  determine  its  nature. 

Fever.  The  presence  of  fever  is  against  intestinal  colic,  and  points 
to  inflammation  in  some  portion  of  the  abdomen;  moreover,  in  inflam- 
mation the  pain  is  constant,  but  localized  and  aggravated  by  pressure. 
The  skin  is  hot  and  dry. 

Diarrhoea.  Diarrhoea  is  a  symptom  of  disorder  of  the  intestine, 
which  in  turn  is  itself  the  cause  of  symptoms,  just  as  jaundice,  a  symp- 
tom of  hepatic  disorder,  is  the  cause  of  various  symptoms.  In  diar- 
rhoea there  is  increased  frequency  of  the  movements  of  the  bowels. 
This  is  due  to  increased  peristalsis  of  the  intestine,  which  occurs  from 
a  number  of  causes.  Not  all  increased  peristalsis  results  in  diarrhoea. 
(A)   Nervous  diarrhoea.      Increased    peristalsis  may  be  due  to  some 


564  SPECIAL  DIAGNOSIS. 

impression  upon  the  nervous  mechanism  of  the  intestine.  This  may 
explain  the  diarrhoea  of  emotion,  or  that  which  occurs  from  other 
psychical  influences.  (B)  Catarrhal  diarrhoea.  In  the  larger  num- 
ber of  cases  the  diarrhoea  is  due  to  catarrhal  inflammation  of  the 
intestinal  tract.  The  causes  of  the  catarrhal  inflammation  are  many, 
and  have  been  divided  into  primary  and  secondary  causes.  Primary 
catarrh  is  due  to  the  direct  influence  of  causal  factors  upon  the  mucous 
membrane.  (1)  It  is  seen  after  cold  or  exposure  ;  (2)  it  occurs  from 
the  direct  irritation  of  undigested  food,  and  (3)  from  the  action  of 
irritants,  as  of  bacteria  or  the  products  of  bacteria.  Catarrhal  inflam- 
mation due  to  micro-organisms  is  the  most  frequent  form  that  occurs 
in  children. 

Secondary  catarrhs  follow  other  lesions  of  more  pronounced  char- 
acter, as  ulcers.  The  catarrh,  and  hence  the  diarrhoea,  that  attends 
the  ulceration  of  typhoid  fever,  the  ulceration  of  dysentery,  or  that 
occurs  in  Bright' s  disease,  and  the  diarrhoea  that  attends  carcinoma 
or  other  organic  disease  of  the  bowel,  is  of  this  nature.  In  addition, 
a  catarrh  of  the  bowels  arises  from  venous  stasis  in  the  mucous  mem- 
brane, with  chronic  congestion.  This  occurs  in  organic  heart  disease 
with  congestion  of  the  liver. 

Diarrhoea  is  a  symptom  of  the  action  of  certain  poisons,  such  as 
mercury,  arsenic,  and  other  corrosive  agents.  The  diarrhoea  which 
occurs  from  the  irritant  action  of  food-products  and  in  cholera  in- 
fantum is  due  to  a  toxic  ptomaine. 

Diarrhoea  sometimes  fulfils  a  vicarious  office.  This  is  the  case  with 
the  diarrhoea  which  comes  on  in  cases  of  chronic  Bright' s  disease,  and 
in  acute  Bright' s  disease  before  the  supervention  of  uraemia.  When 
diarrhoea  occurs  in  a  person  with  pallor,  dimness  of  vision,  and  oedema, 
the  urine  should  always  be  examined. 

The  Symptoms  of  Diarrhoea.  Increased,  movements  of  the  bowels. 
The  frequency  of  the  movements  varies  with  the  cause.  In  the  diar- 
rhoea of  nervous  origin,  usually  after  five  or  six  movements  have 
occurred,  the  patient  is  relieved,  because  the  cause  for  the  nervousness 
has  disappeared.  In  catarrhal  diarrhoea  the  number  varies  from  half 
a  dozen  in  twenty-four  hours  to  the  same  number  in  an  hour.  Indeed, 
in  some  severe  cases  the  evacuations  may  be  almost  constant. 

Character  of  the  movements.  The  movements  may  be  (1)  fwcal,  with 
a  small  amount  of  water.  They  are  light  in  color,  softer  than  natural, 
but  yet  retain  their  form.  They  are  the  kind  of  movements  seen  in 
simple  catarrh. 

2.  The  f secal  matter  is  mixed  with  undigested  food.  The  faeces  are 
in  scybalous  masses,  and  the  watery  element  is  increased.  They  are 
the  stools  of  the  so-called  dyspeptic  diarrhoea. 

3.  Along  with  the  fasces  more  or  less  mucus  is  seen.  The  amount 
of  mucus  depends  upon  the  seat  as  well  as  the  intensity  of  the  inflam- 
mation. Inflammations  of  the  large  intestine  are  attended  with  mucous 
discharge.  It  may  be  mixed  with  and  stained  by  fasces  so  that  it  can 
be  recognized  only  by  close  inspection.  In  milder  degrees  of  catarrh 
it  is  seen  on  the  surface  of  the  faecal  masses. 

4.  The  fseces  disappear  almost  entirely,  and  instead  the  evacuations 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     565 

are  watery.  The  watery  evacuations  may  be  discolored,  as  in  the  pea- 
soup  evacuations  of  typhoid  fever,  or  they  may  be  almost  clear  water, 
as  in  the  rice-water  discharges  of  cholera. 

5.  The  evacuations  may  contain  blood.  Bloody  discharge  usually 
accompanies  the  discharge  of  mucus  ;  when  the  catarrh  is  in  the  lower 
bowel  blood  may  occur  independently  of  the  mucus.  If  with  the 
mucus,  it  tinges  it  in  reddish  specks,  or  small  amounts  of  free  blood 
are  seen.  The  blood  may  be  bright  in  color,  and  then  usually  comes 
from  the  rectum.  It  must  be  remembered  that  the  blood  may  be  from 
hemorrhoids,  or  fissure,  which  is  unduly  irritated  by  the  diarrhoea.  It 
is  then  bright  red  and  unmixed  with  the  movement,  and  from  its  posi- 
tion can  readily  be  seen  to  have  followed  it.  On  the  other  hand, 
it  may  be  due  to  cirrhosis  of  the  liver,  with  venous  congestion.  It 
may  be  due  to  the  ulceration  of  typhoid  fever  and  the  intense  inflam- 
mation of  enteritis.  It  is  a  symptom  of  carcinoma  of  the  bowel  and 
is  of  frecment  occurrence,  almost  pathognomonic,  in  intussusception. 
It  must  be  remembered  that  blood  of  this  character  is  discharged  from 
the  bowel  independently  of  diseases  of  that  tube,  as  in  purpura,  scurvy 
and  other  blood  diseases  (see  Arteries  of  the  Intestine,  page,  560). 
If  mixed  with  the  movement,  the  blood  may  be  black,  as  in  all  forms 
of  melcena,  or  it  may  be  dark  red  in  color.  The  black  blood  usually 
comes  from  the  stomach  or  the  first  part  of  the  duodenum,  and  may 
be  the  result  of  ulceration,  or  even  from  the  swallowing  of  blood. 

Microscopical  and  Bacteriological  Examination.  (See  Fseces.)  In 
simple  catarrhal  inflammation  of  the  tubules,  on  microscopical  exam- 
ination but  little  is  found  except  an  excess  of  epithelium  from  the 
mucous  lining.  In  more  intense  inflammations,  in  addition  to  epithe- 
lium, we  find  pus  and  blood  and  mucus.  Micro-organisms  are  found, 
the  kind  depending  upon  the  cause  of  the  diarrhoea.  In  health  Booker 
has  found  at  least  forty  varieties  of  micro-organisms,  many  of  which, 
in  all  probability,  are  not  pathogenic.  In  health  the  bacillus  coli 
communis  and  the  bacterium  lactis  aeriformis  are  found.  In  the 
diarrhoea  of  children  both  forms  are  present  in  excessive  numbers, 
because  conditions  favoring  their  growth  arise,  and  in  all  probability 
are  the  cause  of  the  irritation  of  the  bowel.  In  that  form  of  inflam- 
mation of  the  bowel  known  as  dysentery,  in  addition  to  the  bacteria 
that  attend  inflammations,  the  amoeba  coli  is  often  present.  It  has 
been  found  that  dysentery  may  be  due  to  a  number  of  causes,  but  that 
the  so-called  tropical  dysentery  is  due  to  the  protozoa  first  described 
by  Kartulis,  in  Egypt,  and  in  this  country  by  Osier  (see  Faeces). 

The  symptoms  that  attend  increased  movement  of  the  bowels  depend 
upon  the  cans:'  and  also  have  direct  relationship  to  the  frecmency  of  the 
evacuation.  The  most  frequent  symptoms  are  pain,  flatulent  disten- 
tion, with  borborygmi  and  tenesmus.  Pain.  The  pain  depends  largely 
upon  the  cause.  If  the  irritant  is  a  product  of  indigestion,  or  a  bulky 
mass,  |>;iin  is  more  or  less  severe.  It  is  situated  in  the  centre  of  the 
abdomen,  and  may  extend  all  over  it.  Pain  occurs  before  the  evacua- 
tion ;  it  i->  sharp,  lancinating,  and  is  usually  relieved  by  the  movement. 
If  the  inflammation  is  in  the  large  intestine,  the  pain  may  be  complained 
of  in  the  course  of  the  lame  bowel  or  be  more  intense  over  the  caecum 


566  SPECIAL  DIAGNOSIS. 

and  the  sigmoid  flexure.  The  rectum  may  be  the  seat  of  pain  or  of 
painful  sensations.  This  has  been  described  as  a  feeling  of  a  hot  ball 
in  the  lower  pelvis.  Flatulent  Distention.  The  flatulent  distention  is 
not  very  great  generally.  The  abdomen  is  distended,  tympanitic  on 
percussion,  and  tender  on  palpation,  both  of  which  may  be  more  marked 
in  the  middle  of  the  abdomen  if  enteritis  alone  is  present,  or  it  may 
extend  along  the  course  of  the  colon,  as  in  the  so-called  entero-colitis  of 
children.  With  the  distention  there  are  borborygmi.  The  rumbling 
usually  subsides  after  the  evacuation. 

Tenesmus  occurs  in  all  forms  of  diarrhoea  if  the  evacuations  have 
been  frequent.  After  the  discharge  of  the  contents  of  the  bowel,  par- 
ticularly if  from  the  rectum,  the  tenesmus  is  much  more  severe,  and 
may  be  of  constant  occurrence.  In  the  severe  cases  the  tenesmus  may 
be  almost  continual.  On  account  of  it  prolapse  of  the  bowel  is  apt 
to  ensue. 

General  Symptoms.  The  general  symptoms  that  attend  diarrhoea 
depend  upon  the  cause.  In  simple  diarrhoea  there  might  be  slight 
feverishness  only,  with  a  little  weakness.  In  diarrhoea,  with  excessive 
movements,  with  mucus,  with  or  without  blood,  the  fever  is  marked 
and  may  rise  as  high  as  103°.  The  fever  that  attends  dysentery  is 
high,  and  usually  rises  rapidly  at  the  beginning. 

Prostration.  More  or  less  prostration  attends  all  cases.  It  is,  how- 
ever, more  marked  when  there  are  frequent  watery  evacuations.  In 
its  most  pronounced  degree  it  is  seen  in  cholera  and  cholera  infantum. 
Collapse  rapidly  ensues  under  these  circumstances  on  account  of  the 
depleting  effects  of  the  excessive  watery  discharge.  In  catarrh  of  the 
intestines  secondary  to  typhoid  fever  and  other  conditions  the  general 
symptoms  depend  upon  the  primary  disease. 

Chronic  Diarrhcea.  Chronic  diarrhoea  may  be  due  to  chronic 
inflammation  of  the  bowels,  as  in  chronic  intestinal  catarrh.  It  may 
be  secondary  to  the  ulceration  of  dysentery,  tuberculosis,  syphilis,  or 
cancer.  It  is  the  common  diarrhoea  of  amyloid  disease.  In  chronic 
diarrhoea  the  number  of  the  stools  varies,  but  seldom  amounts  to  more 
than  ten  to  fifteen  in  a  day.  In  chronic  intestinal  catarrh  three  or 
four  movements  occur  in  the  twenty-four  hours.  They  usually  occur 
in  the  morning,  the  first  evacuation  taking  place  immediately  on  rising 
and  the  remainder  during  the  morning  hours.  They  are  more  common 
in  women  than  in  men,  and  are  readily  excited  by  exhaustion  or  ner- 
vous influence,  as  grief,  emotion,  or  excitement  of  any  kind.  The 
stools  are  fecal  and  watery,  and  contain  some  mucus.  The  mucus 
usually  coats  the  surface  of  the  feces.  The  color  of  the  feces  is  not 
changed.  The  patients  usually  suffer  from  intestinal  dyspepsia  or  they 
are  subject  to  some  gastric  neurosis.  .They  are  not  under  weight,  and 
except  for  the  inconvenience  of  the  morning  hours  could  attend  to  the 
ordinary  demands  of  life.  They  are  more  nervous  than  most  people, 
and  are  liable  to  attacks  of  hemicrania. 

Membranous  Diarrhcea.  In  a  number  of  cases  the  discharge 
from  the  bowels  resembles  membrane.  The  disease  is  also  called  mem- 
branous enteritis.  The  discharge  contains  much  mucus,  and  may  be  a 
little  more  watery.   After  the  feces  have  been  passed  membrane  is  dis- 


DISEASES  OF  STOMACH.  INTESTINES,  AND  PERITONEUM.     567 

charged.  This  may  be  in  shreds  or  large  masses,  and  may  also  be 
like  a  cast  of  the  bowel.  The  patients  are  usually  women  who  are 
hysterical  and  have  some  menstrual  disorder.  Pain  may  precede  the 
discharge,  and  continue  until  there  is  complete  relief. 

Constipation.  Constipation  may  be  due  to  a  number  of  causes. 
It  may  be  due  to  alteration  or  diminution  in  the  secretions  of  the 
intestinal  tract,  as  is  seen  in  all  fevers,  except  when  they  are  attended 
by  specific  intestinal  catarrh,  as  in  typhoid  fever.  Such  diminution 
of  secretion  occurs  in  the  summer,  when  there  is  more  free  perspira- 
tion than  in  other  seasons,  and  is  present  in  affections  attended  by 
excess  of  perspiration,  or  exhaustive  diuresis.  Constipation,  there- 
fore, is  a  common  symptom  of  diabetes. 

In  addition  to  alteration  of  the  secretion,  diminution  in  the  sensi- 
bility of  the  nerves  may  exist.  This  is  the  one  chief  cause  of  habitual 
constipation  that  is  so  prevalent.  On  account  of  carelessness  the 
patient  loses  the  habit  of  having  a  regular  movement  of  the  bowel  each 
day,  and  in  consequence  the  usual  stimulus  is  removed.  Constipation 
also  occurs  from  weakness  of  the  muscles. 

The  three  conditions — diminution  or  alteration  in  the  secretions, 
debility  of  the  muscles,  and  impairment  of  the  sensibility  of  the  ner- 
vous mechanism — are  combined  influences  on  account  of  which  consti- 
pation is  so  prevalent  in  persons  of  sedentary  habits  and  in  persons 
living  upon  improper  diet.  General  diseases  and  local  disorders  which 
influence  either  of  the  above  elements  cause  constipation.  Thus  in 
anaemia  and  chlorosis,  in  neurasthenia  and  hysteria,  constipation  is  a 
common  condition.  Its  occurrence  in  fevers  has  been  mentioned.  In 
the  convalescence  from  exhausting  disease  and  prolonged  confinement 
to  bed  constipation  is  apt  to  ensue. 

Local  Causes.  Atony  of  the  abdominal  muscles  or  of  the  bowel  is 
the  cause.  Atony  is  most  strikingly  seen  in  peritonitis  and  typhlitis, 
in  both  of  which  a  paretic  state  of  the  bowels  develops.  It  is  seen  in 
the  aged  and  in  cachexia  along  with  atony  of  other  muscles.  Obstruc- 
tion of  the  bowels,  acute  or  chronic,  usually  causes  constipation  (q.  v.). 
If  the  obstruction  is  not  complete,  there  may  be  diarrhoea  on  account  of 
catarrhal  inflammation.  Constipation  often  occurs  on  account  of  pain, 
particularly  pain  seated  in  the  ret  turn.  The  pain  is  such  that  the  patient 
shrinks  from  an  evacuation.  Frequent  postponement  soon  causes  con- 
stipation. The  pain  may  be  due  to  fissures,  to  hemorrhoids,  or  to 
fistula.  Constipation  occurs  also  from  local  diseases  in  other  portions 
of  the  body,  influencing,  in  all  probability,  the  nervous  mechanism  by 
which  peristaltic  action  is  excited.  In  acute  and  chronic  disease  of  the 
brain  and  cord,  as  meningitis  and  myelitis,  constipation  is  a  chronic 
attendant.  It  also  occurs  in  tetanus.  If  the  bowel  is  deprived  of 
faecal  matter,  evacuations  cease.  Constipation  is  a  common  sign  of 
stricture  of  the  pylorus  and  of  stricture  or  cancer  of  the  oesophagus. 

Symptoms  of  Constipation.  Constipation  is  characterized  by  diminu- 
tion in  the  frequency  of  the  bowel-movements.  The  frequency  of  the 
movements  varies  in  health.  Some  persons  are  comfortable  with  an 
evacuation  taking  place  once  a  week,  or  at  most  every  third  or  fourth 


568  SPECIAL  DIAGNOSIS. 

day.  There  are  cases  on  record  in  which  the  evacuations  took  place 
but  once  a  month.  Cases  of  this  class  are  usually  due  to  muscular 
paralysis  of  the  bowel,  with  secondary  dilatation.  The  accumulation 
of  faeces  is  removed  by  a  sharp  attack  of  diarrhoea,  attended  by  much 
pain.  The  diarrhoea  sometimes  continues  for  twenty -four  hours.  When 
it  sets  in  fever  may  be  present  until  there  is  thorough  evacuation. 

Local  Symptoms.  Usually  the  symptoms  that  attend  constipation  are 
local,  being  due  to  the  discomfort  of  the  accumulation  of  fasces.  The 
local  symptoms  may  be  limited  to  the  rectum  or  extend  throughout  the 
abdomen.  In  the  rectum  there  is  a  sensation  as  of  the  presence  of  a 
mass,  which  may  cause  some  pain.  The  abdomen  is  distended;  there  is 
considerable  rumbling,  and  sometimes  peristaltic  waves  are  seen.  The 
accumulation  of  the  faecal  mass  in  the  bowel  may  set  up  tormina  and 
tenesmus,  and  portions  of  the  mass  may  be  discharged  from  time  to 
time.  In  other  words,  a  diarrhoea  may  occur,  the  diarrhoea  of  con- 
stipation, or  spurious  diarrhoea.  The  stools  are  small,  composed  of 
hard  scybalous  masses,  generally  coated  with  mucus,  and  streaked 
with  blood.  The  evacuation  does  not  give  relief,  and  the  desire  for  a 
movement  may  be  more  or  less  continuous. 

On  examination  in  constipation  with  faecal  accumulations  the  outline 
of  the  colon  may  be  marked  out  by  palpation  and  percussion  of.  the 
distended  abdomen.  In  its  course  masses  are  felt  varying  in  size  from 
a  marble  to  a  base-ball,  and  in  consistence  they  may  be  soft  to  the  pal- 
pating finger;  they  are  never  indurated  like  a  calcareous  mass,  as  gall- 
stones or  a  mass  due  to  malignant  disease. 

General  Symptoms,  While  in  many  instances  the  general  symptoms 
are  of  no  consecpaence,  in  others  the  patients  are  nervous  and  may  be 
in  more  or  less  impaired  health  on  account  of  the  secondary  effects  upon 
the  stomach.  Digestion  is  impaired  and  the  form  of  indigestion  is 
that  which  attends  neurasthenia. 

The  patients  are  of  spare  habit,  usually  of  dark  or  muddy  com- 
plexion. They  may  be  depressed.  There  is  inaptitude  for  mental 
exertion  ;  they  are  more  or  less  hypochondriacal.  The  tongue  is  con- 
stantly furred,  the  appetite  variable;  there  are  weight  and  fulness  after 
eating,  and  generally  some  flatulency. 

The  Secondary  Effects  of  Constipation.  The  effects  of  constipation 
upon  the  intestines  are  various  and  sometimes  disastrous.  They  are 
dilatation  and  ulceration.  The  former  may  become  enormous,  as  in 
cases  reported  by  Formad  and  Osier.  The  dilatation  may  be  so  great 
as  to  distend  the  entire  abdomen.  The  ulceration  may  be  localized  to 
the  rectum,  or  caecum,  or  extend  throughout  the  entire  large  intestine. 
On  palpation  the  course  of  the  colon  is  tender,  and  faecal  mas-es  may 
be  outlined  and  may  be  painful  because  of  their  pressure  upon  the 
adjacent  ulcer.  In  the  rectum  the  ulcef  may  be  deep,  and  be  followed 
by  peri-rectal  abscess. 

In  the  caecum  the  accumulation  may  be  such  as  to  cause  a  large 
boggy  swelling,  extending  in  the  course  of  the  cfecuni,  which  is  tender 
on  pressure  and  dull  on  percussion.   Stercoral  typhlitis  is  caused  (q.  v.). 

Faecal  impaction,  with  secondary  ulceration,  is  of  frequent  occurrence 
in  typhoid  fever.      This  must  be  borne  in  mind,  for  often  serious  gen- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     569 

eral  and  local  symptoms  arise  because  it  is  overlooked.  Recently  I 
saw  a  case  with  diarrhoea  of  constipation,  with  some  fever,  which  per- 
sisted for  weeks  after  the  usual  course  of  typhoid  fever.  It  was 
thought  the  patient  had  tuberculosis,  or  that  the  typhoid  process  was 
abnormally  prolonged.  Examination  disclosed  ulceration  into  the 
vagina,  and  the  fasces  were  con.^tantly  discharged  from  this  orifice.  It 
had  been  thought  that  the  discharges  of  fasces  were  due  to  diarrhoea. 
Of  course,  fever  attended  the  process,  and  rendered  the  case  all  the 
more  obscure. 

In  this  connection  must  be  mentioned  the  constipation  that  occurs  on 
account  of  lead-poisoning,  and  the  exhibition  of  drugs,  as  opium,  or 
astringents.  The  constipation  of  lead-poisoning  is  usually  attended  by 
colic,  and  the  blue-line  on  the  gums  is  seen,  while  wrist-drop  or  other 
manifestations  of  lead  may  be  present. 

Intestinal  Hemorrhage. 

The  causes  are  general  and  local.  The  general  causes  are  those  that 
accompany  hemorrhage  in  other  localities  (see  Gastric  Hemorrhage). 
The  local  causes  (1)  in  which  hemorrhage  is  small  are  :  inflammation 
of  the  bowel;  traumatic  injury  to  the  bowel  from  hernia,  fasces,  and 
parasites,  and  foreign  bodies  swallowed,  or  from  corro-ive  poison; 
tumors  of  the  bowel,  as  in  cancer,  invagination,  and  ulcers.  (2)  Large 
hemorrhage  occurs  in  the  congestion  attending  portal  obstruction  and 
liver  disease,  or  disease  of  the  heart  with  secondary  obstruction.  Aneu- 
rism of  the  superior  mesenteric  artery,  or  aneurism  rupturing  into  the 
intestine,  and,  occasionally,  embolism  of  the  artery  will  be  followed 
by  intestinal  hemorrhage.  It  occurs  in  ulcers  first  from  typhoid  fever; 
second,  from  dysentery;  third,  from  syphilis.  It  may  occur  in  pyaemia 
and  septicaemia,  or  the  acute  exanthematous  diseases. 

The  symptoms  may  be  those  of  hemorrhage  alone  :  collapse,  pallor, 
failure  of  sight,  tinnitus,  vertigo,  small  pulse,  and  general  restlessness. 
The  hemorrhage  must  be  copious  under  these  circumstances,  and  is  due 
(1)  to  the  bleeding  of  an  ulcer,  as  in  typhoid  fever;  (2)  to  portal  obstruc- 
tion ;  (3)  to  an  aneurism  ;  (4)  to  purpura  or  haemophilia. 

A  second  group  of  symptoms  is  connected  with  the  appearance  of 
the  discharges  from  the  bowels.  The  stools  are  bloody  ;  if  the  hem- 
orrhage is  low  down,  they  are  bright  red  and  usually  mixed  with 
faeces.  If  high  up,  they  are  tarry.  They  are  known  as  melaena  (see 
Faeces). 

The  passage  of  the  stools  is  preceded  by  colicky  pains,  or  there  may 
be  some  rumbling.  The  diagnosis  must  be  directed  toward  determin- 
ing the  cause  of  the  hemorrhage,  as  well  as  its  seat  ;  the  history,  the 
associate  diseases,  <»r  symptoms,  aid  in  determining  the  cause.  Exam- 
ination of  the  rectum  may  afford  a  clue  to  its  origin. 

The  Data  Obtained  by  Observation.     The  Objective  Symptoms. 

PHYSICAL  SIGNS.  Inspection.  Local  and  general  enlargements  of 
the  abdomen  have  been  discussed  in  the  preceding  pages.      Movements 


570  SPECIAL  DIAGNOSIS. 

of '  the  intestines  are  seen  in  obstruction  due  to  increased  peristalsis. 
The  intestine  above  the  point  of  obstruction  may  swell  into  a  well- 
defined  tumor  which  becomes  hard  and  dull,  and  tympanitic  on  per- 
cussion. 

Palpation.  Tenderness,  peristalsis,  peritoneal  friction,  the  bubbling 
of  gas  through  a  constriction  of  the  bowel,  and  tumors,  are  recognized 
by  palpation.  It  is  necessary  often  to  place  the  patient  on  all  fours  or 
in  a  knee-chest  position. 

Percussion.  The  normal  note  is  tympanitic.  Local  areas  of  dulness 
may  be  due  to  intestinal  tumor.  Light  percussion  should  be  employed. 
A  dull  tympany  indicates  a  solid  mass  surrounded  by  the  distended 
intestines.  The  outline  of  the  large  intestine  can  be  ascertained  by 
filling  it  with  water. 

The  Fseces.  General  Considerations  and  Macroscopical 
Appearances.  The  number  of  stools  in  health  varies  chiefly  with 
the  individual  and  the  character  of  the  food  taken.  After  infancy, 
one  passage  in  twenty-four  hours  is  the  rule,  but  it  is  natural  for  some 
persons  to  have  two  or  three,  and  for  others  to  have  but  one  passage 
in  two,  three,  or  four  days.  Such  a  condition  is  termed  constipation, 
while  pathological  constipation  is  properly  called  obstipation.  The 
opposite  condition  is  known  as  diarrhoea.  The  amount  and  character 
of  food  and  drink  ingested  influence  the  number  of  the  stools.  Exer- 
cise also  plays  a  role  ;  increased  or  diminished  peristalsis,  from  what- 
ever cause,  will  induce  diarrhoea  or  constipation,  respectively.  In 
disease  the  greatest  extremes  are  met  with — from  the  non-passage  of 
feces  for  days,  as  in  obstruction,  to  an  almost  continuous  discharge,  as 
in  some  forms  of  intestinal  inflammation.  It  is  well  to  remember  that 
diarrhoea  may  be  the  symptom  of  obstipation,  as  when  impacted  fseces 
in  typhoid  cause  looseness  of  the  bowels. 

The  amount  of  fasces  varies  with  the  quantity  and  nature  of  food. 
If  most  of  the  food  is  digested  and  carried  away  for  the  economy,  there 
will  be  but  little  left  to  form  feces.  In  any  disease  that  prevents  the 
absorption  of  digested  food  or  causes  an  increase  in  the  fluid  contents 
of  the  intestine,  as  cholera,  the  amount  of  feces  will  be  increased.  In 
health  about  140  to  200  grammes  are  voided  in  twenty-four  hours. 

The  form  and  consistence  of  healthy  stools  vary  somewhat.  They 
are  commonly  cylindrical  and  firm  or  mushy.  When  they  remain  long 
in  the  intestinal  canal,  and  the  water  is  extracted,  they  become  hard 
and  may  form  balls,  or  flattened  masses  known  as  scybala.  These  are 
frequently  seen  in  convalescing  typhoid  patients.  On  the  other  hand, 
the  feces  may  be  without  form,  and  are  then  liquid,  either  watery  as 
in  cholera,  or  purulent  or  bloody.  Many  diseases  cause  such  a  con- 
dition. 

The  odor  of  feces  is  sometimes  more  or  less  characteristic  of  certain 
conditions.  Thus  the  stools  of  nursing-infants  have  a  sour  smell,  while 
in  infantile  diarrhoea,  and  when  fermentation  takes  place,  they  have 
an  odor  of  sebacic  acid.  When  urine  is  mixed  with  the  passage  the 
odor  will  be  ammoniacal  ;  with  blood  present  it  often  has  a  stale  odor. 

The  reaction  is  not  constant.  Thus  in  intestinal  catarrh,  with  acid 
fermentation,  it  will  be  acid,  or  in  alkaline  fermentation  it  will  be  alka- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     571 

line.  The  color  of  the  stools  varies  too  much  to  be  of  special  diag- 
nostic value.  In  health  it  is  light  to  dark  brown,  due  chiefly  to  the 
presence  of  hydro-bilirubin,  a  product  of  decomposition  of  bile-pigment, 
which  is  never  normally  found  unaltered  in  the  faeces.  It  is  influenced 
greatly  by  food  and  medicines.  When  certain  berries,  as  huckleberries, 
are  eaten,  or  certain  medicines  taken — iron  and  bismuth — they  make 
the  passages  black.  Calomel  causes  green  stools,  on  account  of  the 
biliverdin  discharged.  Green  stools  may  also  receive  their  color  from 
the  presence  of  a  bacillus  which  produces  a  green  dye.  Santonin, 
rhubarb,  and  senna  cause  yellow,  and  hsematoxylon  red  stools.  The 
last  fact  is  important,  as  parents  or  nurses  should  always  be  warned 
to  expect  red  passages  when  haematoxylon  is  given. 

The  faeces  may  be  red  or  reddish  from  the  presence  of  unaltered 
blood  ;  or  black,  when  the  blood  has  undergone  changes;  the  so-called 
"  tarry  stools"  are  of  this  character.  With  a  decrease  in  the  amount 
of  bile  the  stools  become  less  colored,  and  if  the  bile  is  cut  off  they 
become  clayey.  This  color  may,  in  some  cases,  be  due  to  the  presence 
of  fat  left  undigested  because  of  the  lack  of  bile.  On  the  other  hand, 
if  from  disorders  of  the  stomach  and  intestine  the  contents  pass  through 
too  rapidly,  the  faeces  may  contain  unaltered  bile  or  unchanged  bile-pig- 
ment, giving  a  green  or  yellow  color,  and  showing  the  bile-reaction. 

The  constituents  offceces  that  can  be  recognized  by  the  naked  eye  are 
numerous.  Seeds,  stones,  skins  of  fruit  and  berries,  and  the  fibres 
of  vegetables  are  often  seen  in  healthy  stools.  In  the  passages  of  chil- 
dren and  weak-minded  individuals  foreign  substances  of  all  descriptions 
may  be  present.  Foreign  bodies  and  partially  digested  portions  of  food 
may  be  mistaken  for  parasites.  Portions  of  tumors  from  the  digestive 
tract  may  appear  in  the  faeces. 

In  certain  diseases  of  the  stomach  and  small  intestine,  and  in  those 
who  eat  very  fast  and  do  not  properly  masticate  their  food,  undigested 
and  unchanged  particles  of  food  may  be  seen  in  the  stools. 

Shreds  of  mucous  membrane  cf  varying  size  are  passed  with  the 
faeces,  or  constitute  them,  in  cases  of  membranous  enteritis.  Von 
Jaksch  saw  such  a  shred  5  cm.  long  and  3  cm.  broad  in  a  case  of 
cholelithiasis. 

Particles  resembling  sago-grains,  perhaps  the  result  of  over-indul- 
gence in  farinaceous  food,  have  been  met  with. 

Gallstones  in  the  faeces  have  great  clinical  value.  They  may  escape 
detection,  if  not  properly  sought  for.  When  suspected,  each  passage 
should  be  passed  through  a  linen  sieve,  the  faecal  masses  being  softened 
with  water.  They  may  be  found  as  small,  crumbling  masses,  com- 
posed chiefly  of  cholesterin  (intrahepatic  calculi),  or  as  hard,  irregular, 
smoothly  worn,  shining,  many-sided,  hard  stones,  sometimes  as  large 
as  an  egg,  usually  the  size  of  a  pea.  Enteroliths  are  occasionally  seen. 
They  are  said  to  originate  in  the  appendix. 

Blood  may  be  present  in  the  faeces  in  varying  proportions  and  con- 
ditions. When  found  unaltered  on  the  surface  of  scybalous  masses, 
it  is  from  the  rectum  or  large  intestine,  and  probably  the  result  of 
traumatism.  Hemorrhoids,  if  bleeding,  may  cause  such  an  appearance, 
or  may  cause  very  free  hemorrhage.   Severe  hemorrhage  may  come  from 


572  SPECIAL  DIAGNOSIS. 

ulceration  of  the  rectum  or  colon,  due  to  malignant  disease  or  severe 
inflammation.  The  blood  may  be  intimately  mixed  with  the  fa?ces, 
and  have  its  origin  in  the  large  intesfne,  but  much  more  commonly  it 
indicates  a  source  iu  the  stomach  or  small  intestine.  Under  such  cir- 
cumstances it  is  nearly  always  more  or  less  changed  by  the  intestinal 
juices,  and  is  brownish-red  or  black  (the  tarry  stool  mentioned  above), 
or  has  the  appearance  of  coffee-grounds.  The  brighter  the  color  of 
the  blood  the  nearer  is  the  source  of  hemorrhage  to  the  amis.  The 
more  retarded  the  passage  the  greater  the  change;  while,  if  quickly 
expelled,  blood  from  the  small  intestine  may  be  passed  unchanged, 
as  in  the  hemorrhage  of  typhoid  fever.  The  micro-cope  detects  blood 
when  die  naked  eye  fails  to  detect  it.  .  It  is  to  be  remembered  that 
certain  drugs,  as  already  stated,  may  color  the  faeces  red,  and  simu- 
late blood. 

Mucus  may  be  present  in  the  passages  in  health,  but  when  in  any 
marked  quantify  there  is  a  catarrh  of  the  mucous  membrane  of  the 
intestines.  When  hard  scybala  are  covered  with  mucus,  or  the  mucus 
is  seen  in  shreds,  the  large  intestine  is  the  seat  of  a  catarrh  ;  although 
mucus  may  be  mixed  with  thin  stools,  as  in  dysentery.  Usually,  how- 
ever, when  the  mucus  is  finely  divided  and  mixed  with  the  faeces,  it 
comes  from  the  small  intestine.  Mucous  shreds  have  already  been 
mentioned.  In  cholera  the  panicles  of  mucus  look  like  boiled  rice, 
hence  the  term  "  rice-water  stool." 

Fatty  stools,  to  the  naked  eye,  appear  greasy  or  even  clayey,  when 
there  is  much  fat,  even  though  bile-pigment  may  be  present. 

Pus  may  be  present  in  large  quantities  from  rupture  of  an  abscess 
into  the  intestinal  tract,  or  when  there  are  ulcerations  from  various  con- 
ditions, producing  pus  in  considerable  quantities. 

Many  animal  parasites  are  visible  to  the  naked  eye,  but  a  full  con- 
sideration of  them  will  be  given  in  the  following  paragraphs. 

Microscopical  Examination  of  the  F^ces.  A  small  portion 
of  the  solid  fasces  to  be  examined  is  placed  on  a  slide,  moistened  with 
watar  and  \  per  cent,  salt  solution,  and  a  cover-slip  applied  ;  or  if 
liquid,  various  drops  are  to  be  examined.  The  different  constituents 
found  will  vary  with  the  food  taken  as  well  as  with  disease. 

Constituents  Derived  from  Food.  There  may  be  portions  of 
digested  or  undigested  food.  In  general  it  may  be  said  that  the  pres- 
ence of  large  pieces  of  unchanged  food  or  many  small  particles  of 
undigested  or  only  partially  digested  food,  indicates  defective  digestion 
in  the  stomach  or  small  intestine.  If  unchanged  bile  is  present,  some 
particles  will  be  colored  yellow,  another  indication  of  disordered  func- 
tion. 

From  the  food  we  may  see  muscle  and  elastic  fibres,  more  or  less, 
according  to  the  quantity  of  meat  eaten  by  the  patient.  The  former 
are  recognized  by  their  transverse  striation;  the  latter,  by  their  double 
contour  and  curling  ends.  Fat  may  be  present  as  fatty  globules  or  in 
the  form  of  needles,  fatty  crystals.  Much  fatty  food  increases  their 
number,  and  they  are  seen  plentifully  in  alcoholic  poisoning,  in  jaun- 
dice, in  the  fatty  pancreatic  diseases,  tuberculosis  of  intestines,  diseases 
of  the  mesenteric  glands,  and  enteritis.      The  crystals  may  be  trans- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     573 


formed  into  fat-drops  by  the  addition  of  acid  and  heat.  When  meat 
is  eaten  freely,  areolar  tissue  may  be  present,  but  its  presence  otherwise 
points  to  'defective  digestion.  Various  forms  of  vegetable  cells  are 
commonly  seen,  in  which  granules  of  starch  may  be  contained,  or  the 
starch  particle  may  be  free.  Undigested  milk  occurs  in  the  stools  of 
children  and  when  diarrhoea  prevails  ;  a  substance,  probably  casein, 
has  been  described  by  Nothnagel  as  occurring  in  faeces  of  persons  who 
have  intestinal  disturbances. 

In  persons  living  on  vegetables  most  of  the  above  constituents  will 
be  absent,  and  in  infants  who  partake  only  of  milk,  the  derivatives  of 
meat  are  absent,  while  there  will  be  an  excess  of  fatty  crystals  and 
fat-globules  and  coagulated  products. 


Fig.  105. 


Collective  view  of  the  faeces.  (Eye-piece  III.,  objective  8A,  Reichert.)  a.  Muscle-fibres,  b.  Con- 
nective tissue,  c.  Epithelium,  d.  White  blood-corpuscles,  e.  Spiral  cells  f-i.  Various  vegetable 
cells,  k.  Triple  phosphate  crystals  'in  a  mass  of  various  micro-organisms.  I:  Diatoms.  (Von 
Jaksch.) 


Constituents  from  the  Alimentary  Tract.  Epithelium.  In 
every  normal  stool  will  be  found  epithelium  of  the  squamous  variety. 

Occasionally  the  columnar  form  is  seen,  and  modified  epithelial  cells 
are  very  common.  In  intestinal  catarrh  their  number  is  greatly  in- 
creased. 

Red  Blood-corpusdes.  In  the  majority  of  blood-stained  stools  red 
blood-cells  are  not  found  ;  in  their  stead  will  be  seen  masses  of  free 
blood-coloring  matter  and  rhombic  crystals  of  hsematoidin.  Red  cells 
are  seen  in  dysenteries,  in  bloody  stools  in  which  the  blood  comes  from 
near  the  anus,  as  in  hemorrhoids,  and  when  blood  is  discharged  with  the 
fseces  soon  after  the  occurrence  of  the  bleeding.  If  there  is  any  doubt 
as  to  the  presence  of  blood,  when  the  corpuscle  cannot  be  found,  a  true 
decision  can  be  reached  by  examining  for  haimin-crystals,  according  to 
IVirlimann's  method.  A  portion  of  fasces  is  dried  and  powdered, 
placed  on  a  slide  with  a  grain  of  common  salt,  and  covered  by  a  cover- 
slip.  A  few  drops  of  glacial  acetic  acid  are  directed  beneath  the  slip, 
the  slide  is  heated  just  to  boiling,  and  if  blood  has  been  present,  red- 
dish-brown rhombic  crystals  of  hsemin  will  soon  be  found. 

Leucocytes.    Leucocytes  are  frequently  seen  in  healthy  stools.    When 


574  SPECIAL  DIAGNOSIS. 

pus  is  present  or  discharged  into  the  intestinal  canal  they  are  found 
in  great  numbers,  as  in  ulceration  of  the  intestine  and  in  abscess. 

Molecular  debris,  or  detritus,  occurs  in  all  faeces  as  part  of  the  waste- 
products. 

Crystals,  i^-crystals  are  the  most  important.  They  have  been 
quite  fully  considered  above.  There  seems  to  be  little  doubt  that  the 
crystalline  needles  found  in  the  faeces  are  salts  and  fatty  acids,  and  not 
tyrosin. 

Char  cot-Ley  den  crystals,  similar  to  those  already  described  (see 
Sputum),  have  occasionally  been  met  with  in  the  stools  of  typhoid  fever 
patients,  in  dysentery,  intestinal  tuberculosis,  and  ankylostomiasis. 

Hwmatoidin- crystals  occur  as  reddish-brown,  hard,  needle-shaped 
bodies,  usually  in  clusters,  and  free  or  enclosed  in  masses  of  mucin  or 
a  substance  resembling  it.  They  have  been  found  in  the  faeces  of 
breast-fed  infants,  in  cases  of  chronic  intestinal  catarrh,  and,  by  Von 
Jaksch,  in  the  stools  of  a  case  of  nephritis. 

Crystals  of  various  salts  of  calcium,  of  triple  phosphate  and  cholesterin 
will  often  be  recognized,  but  they  have  no  diagnostic  value.  When 
bismuth  is  being  administered,  black  rhombic  crystals  of  the  sulphide 
of  bismuth  will  be  recognized. 

Parasites.  (A)  Animal  and  (B)  vegetable  parasites  nourish  in 
the  intestinal  tract,  and  the  presence  of  some  of  these  in  the  faeces  is 
of  the  greatest  clinical  importance. 

A.  Animal  Parasites.  Following  Leuckart's  classification,  we 
will  consider  these  parasites  under  the  secondary  heads  : 

I.  Protozoa.  1.  Rhizojioda.  This  variety  is  made  important 
bceause  the  amoeba  dysenteriae  or  amoeba  coli  belongs  to  it. 

(a)  Amoeba  Dysenterice.  Amoeba,  Coli.  This  protozoon  has  been 
found  so  many  times  by  various  observers  in  different  parts  of  the 
world  that  it  can  now  be  considered  to  be  the  causative  factor  of  so- 
called  tropical  dysentery.  The  subject  has  received  special  study  in 
our  own  country  by  Osier,1  Stengel,2  Dock,3  and  Councilman  and 
Lafleur.4  The  work  of  Councilman  and  Lafleur  is  at  the  present  time 
the  best  that  has  been  published  in  any  country;  and  to  it  the  reader 
is  particularly  referred.      The  following  notes  are  based  on  this  book. 

The  amoebae  dysenteriae  vary  in  size  from  0.012  to  0.035  mm.  They 
are  found  most  plentifully  in  the  small  gelatinous  masses  often  to  be 
seen  in  the  faeces.  They  vary  in  number  in  different  cases,  and  in  the 
same  case  at  different  times.  The  severer  the  lesions  the  more  numer- 
ous are  the  amoebae.  When  not  active  they  are  round  or  oblong,  and 
highly  refractive.  They  contain  one  or  more  vacuoles  of  varying  size. 
Occasionally  the  division  into  an  ecto-  and  endosarc  is  easily  made  out. 
When  thus  inactive  they  may  be  confounded  with  swollen  connective- 
tissue  cells  and  compound  granular  bodies  found  in  faeces.  The  active 
amoebae  have,  however,  a  characteristic  movement.  Tins  consists  of 
progression  and  of  thrusting-out  and  retraction  of  pseudopodia.  Their 
activity  varies  greatly.     It  is  best  seen  when  the  body-heat  is  niain- 

1  Johns  Hopkins  Hospital  Bulletin,  May,  1890,  vol.  i.  No.  5. 

2  Phila.  Med.  News,  1890.  s  Texas  Med.  Journal,  April,  1891. 
4  Johns  Hopkins  Hospital  Reports,  vol.  ii.  Nos.  7,  8,  9. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     575 

tained.  The  stools  should  be  passed  into  a  clean  aud  warm  pan,  and 
examined  immediately,  or  kept  warm  until  examined,  and  a  warm 
stage  should  be  used  with  the  microscope.  The  division  into  ecto- 
and  endosarc  is  usually  clear  during  activity.  The  ectosarc  is  com- 
posed of  a  hyaline  homogeneous  mass,  as  are  the  pseudopodia,  while 
the  endosarc  is  made  up,  not  of  granular  matter,  but  of  a  dense  homo- 
geneous mass  enclosing  vacuoles  and  a  nucleus.  The  vacuoles  may 
vary  in  size  as  well  as  in  number.  There  may  be  one  or  two  large 
ones,  or  the  entire  eiidosarc  may  appear  as  made  up  entirely  of  small 
vacuoles.  The  nucleus  is  sometimes  plainly  seen  as  a  small  rounded 
body,  but  is  more  often  difficult  to  distinguish  from  the  vacuoles. 
Dried  cover-slip  preparations  may  be  stained  with  the  various  aniline 
dyes,  but  the  results  are  not  satisfactory. 

The  amoebae  will  often  be  found  to  enclose  bodies  such  as  red  blood- 
corpuscles,  pus  cells,  blood-coloring  matter,  bacilli  and  micrococci. 


Fig.  106. 


0g\ 


Amoeba,  coli.    (Hallopeau.) 


In  examining  the  faeces  for  amoebse  dysenterise  the  suggestion  given 
above  concerning  the  warm  bed-pan  and  warm  stage  to  the  microscope, 
and  above  all,  the  immediate  examination  of  the  stool,  should  be 
adhered  to.  The  small  gelatinous  masses  should  be  selected  when 
present.  Various  magnifying  powers  should  be  used,  including  the  T^ 
oil  immersion  lens. 

(6)  Monadines,  pear-shaped,  with  a  long  slender  process,  are  seen 
alive  in  only  perfectly  fresh  stools.  They  are  not  found  constantly  in 
any  one  disease. 

2.  Sporozoa.  Under  this  head  belongs  the  coccidium  perforans  of 
Leuckart.  They  are  short,  elliptical  bodies,  which  infest  the  intestinal 
mucous  membrane,  and  may  damage  it  badly;  they  are  often  discharged 
in  large  numbers. 

3.  Infusoria.  {<<)  Cercomonas  intestinalis.  This  is  a  pear-shaped 
body,  nucleated,  with  eight  tentacles  of  varying  length.  It  is  found 
in  the  feeces  of  persons  suffering  from  various  diseases,  as  cholera  aud 
typhoid  fever,  aud  probably  of  itself  causes  diarrhoea. 


576 


SPECIAL  DIAGNOSIS. 


(b)  Trichomonas  intestinalis.  Larger  than  the  cercomouas,  and  cov- 
ered with  cilia?  at  the  club  eud.     It  is  not  diagnostic  and  is  not  common. 

(c)  Paramecium  coli.  Larger  than  the  preceding,  1  mm.  long — oval, 
covered  everywhere  with  cilise;  may  be  found  in  diarrhoeic  stools. 

II.  Vermes.  These  are  much  more  generally  known  and  are  of 
much  more  clinical  value  than  the  preceding. 

They  have  important  clinical  value,  as  the  presence  of  some  of  them 
in  the  intestinal  canal  gives  rise  to  many  untoward  symptoms.  They 
will  be  considered  under  (A)  Platodes.      (B)  Annelides. 

A.  Platodes.  1.  Tapeworm — Cestodes.  These  parasites  infest  the 
small  intestine  only,  to  the  walls  of  which  they  cling  by  the  head.  The 
head  and  neck  are  small ;  the  joints  are  flat  and  form  long  ribbons. 
The  distal  joints  continually  drop  off  and  can  easily  be  recognized  in 
the  stools  by  the  naked  eye,  and  the  eggs  by  the  use  of  the  microscope. 
The  fasces  are  best  washed  in  water  and  broken  up  to  obtain  the  eggs. 
As  the  lower  joints  are  lost  new  ones  take  their  place  from  above.  The 
more  important  are  as  follows  : 


Fig.  107. 


Fig.  108. 


Head  of  T.  solium.    X  45.    (Leuckart.) 


Ova  of  T.  solium,  a  with  yolk,  b  without 
yolk,  as  in  mature  segments.  The  hard 
brown  shell  is  indicated.    (Leuckart.) 


a.  Tarnia  solium  (Fig.  107)  reaches  a  length  of  two  to  three  metres. 
The  head  is  the  size  of  a  pin-head.  The  neck  is  2.5  cm.  long,  as 
thick  as  a  thread,  and  without  joints.  The  segments  forming  the  body 
are  short  and  broad  near  the  neck,  but  as  they  increase  in  size  there 
is  more  growth  in  length  than  in  width.  The  average  dimensions  are 
9  to  10  mm.  by  6  or  7  mm.  The  head  appears  dark,  the  body  white. 
The  joints  are  easily  detected  in  the  fseces  by  the  naked  eye.  Under 
the  microscope  the  head  is  seen  to  be  spheroid,  with  four  pigmented 
sucking  discs  surrounding  at  the  base  a  rostellum,  which  is  a  "  crown 
of  hooks" — chitin  hooks — about  twenty-four  in  number.  In  the  ripe 
segment*,  or  proglottides,  is  seen  the  longitudinal  uterus  with  about 
twelve  horizontal  ramifications  to  a  segment.     The  eggs  are  round  or 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     577 

oval,  0.035  mm.  long,  with  a  thick,  striated  shell  when  ripe,  and  con- 
tain hooklets. 

b.  Tcenia  mediocanellata,  or  saginata.  This  worm  is  four  or  five 
metres  long.  The  head  is  slightly  larger  than  that  of  the  T.  solium, 
and  more  pigmented,  and  the  segments  are  longer,  fatter,  and  darker. 
The  head  is  supplied  with  four  powerful  sue  king- cups,  but  has  no  ros- 
tellum  or  hooklets.  The  uterus  in  the  ripe  segment  is  much  more 
finely  branched  than  in  the  solium,  and  these  segments  have  inde- 
pendent movement.  The  eggs  are  very  similar  to  those  of  the  T. 
solium,  but  may  be  rather  larger. 

c.  Tcenia  nana.  In  length  the  T.  nana  is  only  10  to  15  mm.,  and 
0.5  mm.  in  breadth.  The  round  head  is  but  0.3  mm.  in  diameter. 
The  segments  are  all  short,  and  at  the  lower  end  of  the  body  are  four 
times  as  wide  as  they  are  long.  The  head  is  found  to  have  four  round 
suckers  at  the  base  of  a  rostellum  that  can  be  inverted.  At  the  base 
of  the  rostellum  are  about  twenty-two  hooklets.  The  uterus  is  oblong 
and  filled  with  eggs.     The  eggs  have  a  double  membrane. 

d.  Tcenia  cuewnerina.  This  parasite  is  found  to  be  5  to  20  cm.  long 
and  about  2  mm.  wide.  The  head  is  placed  at  the  thinner  end,  and  under 
the  microscope  are  to  be  seen  some  sixty  hooklets  regularly  distributed 
about  the  rostellum,  and  four  sucking-cups.  The  lower  segments  are 
decidedly  larger  than  the  upper — 6  by  7  mm.  When  ripe  they  become 
reddish,  and  contain  cocoon-like  bodies,  in  which  are  six  to  twelve 
eggs. 

e.  Bothriocephalus  latus.  This  is  the  largest  of  the  worms,  measur- 
ing 7  or  8  metres.  The  head  is  somewhat  drawn  out,  and  on  either 
side  is  a  long,  narrow  sucker.  There  are  neither  hooks  nor  rostellum. 
The  proglottides  are  short  near  the  head,  but  become  square  further 
down.  The  uterus  appears  as  a  rosette,  peculiar  to  this  worm.  The 
eggs  are  oval  and  measure  7  mm.  by  0.045  mm.,  have  a  shell  covering, 
with  an  opening  like  a  lid  at  one  end.  Eipe  segments  are  thrown  off 
in  bunches,  not  singly. 

It  will  not  be  necessary  to  describe  certain  other  varieties  that  are 
rarely  met  with. 

2.  Trematodes,  or  flukes,  a.  Distoma  hepedicum  measures  28  mm. 
by  10  mm.,  and  is  shaped  like  a  leaf.  A  short  head  is  situated  at 
the  broad  end  and  has  one  sucker  ;  on  the  under  surface  is  another 
sucker,  and  between  the  two  is  the  opening  of  the  uterus,  a  highly 
convoluted  arrangement.  The  eggs  are  brown,  oval,  about  0.12  mm. 
long,  and  have  a  lid  at  one  end.     It  is  not  often  seen. 

b.  Distoma  lanceolatum.  This  round-shaped  worm  is  about  8  mm. 
long  and  3  mm.  broad,  and  in  other  respects  resembles  the  preceding. 
The  eggs  are  more  rounded  and  contain  minute  embryos.  Like  the 
D.  hepaticum,  it  is  rarely  seen. 

c.  Distoma  crassum  is  the  largest — 4  to  8  cm.  long.  These  flukes 
are  endemic  in  parts  of  Japan.  In  general  these  animals  occupy  the 
bile-passages  or  upper  part  of  the  small  intestine. 

B.  Annelides.  1  Round  worms — nematodes,  a.  Ascarides.  a. 
Ascaris  lumbricoides.  This  is  the  parasite  usually  referred  to  by  the 
term  round  worm.     It  resembles  the  common  earth-worm  in  shape  and 

37 


578  SPECIAL  DIAGNOSIS. 

color.  The  male  worm  is  about  250  mm.  long,  and  the  female  400 
mm.  The  head  is  made  up  of  three  prominent  lips,  and  is  supplied 
with  microscopical  teeth.  The  vulva  of  the  female  is  in  the  posterior 
third  of  the  body.  The  eggs  are  rounded,  brownish,  0.06  mm.  in 
diameter,  and  covered,  when  fresh,  by  a  rough  albuminous  coat  over 
a  hard  shell.  This  worm  has  the  small  intestine  for  its  habitat.  It 
may  pass  with  the  stools  or  work  its  way  into  the  stomach  and  be 
vomited  (the  writer  has  had  them  thus  vomited  during  the  etherization 
of  a  child  of  ten  years).  They  have  been  the  cause  of  jaundice  by 
crawling  into  the  ductus  choledochus,  and  may  infest  the  larger  hepatic 
ducts.  Enormous  numbers  may  be  present  in  the  intestine  at  one 
time. 

b.  Oxyuris  verrnicularis.  The  thread-  or  seat-worm  inhabits  the 
large  intestine,  and  is  often  present  in  the  stool  as  a  white,  thread- 
like body;  the  male  5  mm.  and  the  female  10  mm.  long.  They  often 
wander  out  of  the  anus  and  into  the  vagina.  The  head  has  a  number 
of  small  lips,  and  is  covered  with  a  thick  skin.  The  female  has  one 
vagina  and  two  uteri.  The  eggs  are  unsymmetrical,  have  a  laminated 
shell  and  a  diameter  of  about  4  mm. 

B.  Strongylicle*.  Ankylostomum  duodenale.  This  is  a  round  worm, 
reaching  a  length  of  6  to  10  mm.  in  the  male  and  10  to  18  mm.  in  the 
female,  and  can,  therefore,  be  seen  easily,  though  the  eggs  are  much 
more  frequently  found  in  the  stool  than  is  the  worm  itself.  With  the 
eggs  there  may  be  present  in  the  stools  large  numbers  of  Charcot- 
Leyclen  crystals.  The  head  is  prominent,  especially  in  the  male. 
Four  hook-like  teeth  surround  the  mouth,  and  by  these  the  animal 
attaches  itself  to  the  intestinal  wall.  The  tail  of  the  male  is  expanded 
and  that  of  the  female  pointed.  The  vulva  is  in  the  posterior  third. 
The  eggs  are  oval,  about  0.05  mm.  in  diameter,  and  contain  one  to 
four  cells — embryonic  globules,  which  rapidly  develop  in  a  warm  place 
outside  the  body,  and  may  thus  be  recognized.  The  worm  infests  the 
small  intestine,  especially  the  jejunum.  It  often  causes  serious  symp- 
toms -  -bloody  stools  and  intense  anaemia. 

C  TriclLotrachelid.es.  a.  Tricocephalus  dispar.  The  whip-worm  is 
4  to  5  cm.  in  length,  the  female  being  longer  than  the  male.  It  is 
recognized  by  the  contrasting  form  of  the  anterior  and  posterior  portions. 
The  former  is  thin  and  threadbare,  the  latter  expanded  and  broad,  and 
in  the  male  curled  up.  The  eggs  are  brownish,  about  0.05  mm.  long 
and  half  as  broad,  and  have  a  button-like  projection  at  either  end  ; 
they  are  to  be  recognized  in  the  stools,  where  large  ones  may  be  pres- 
ent. There  may  be  only  a  few  or  thousands  of  the  forms  present  in 
the  body.  They  live  chiefly  in  the  caecum  and  large  intestine.  They 
have  been  thought  to  cause  beri-beri  by  some  writers. 

b.  Trichina  spiralis.  It  is  the  adult  trichinae  which  exist  in  the 
intestine,  and  are  found  very  infrequently  in  the  fasces.  These  produce 
the  embryos,  which  become  muscle  trichina?.  The  adult  male  is  1. 5  mm. 
long  and  the  female  twice  that  length.  The  former  has  two  projections 
from  the  hinder  end,  between  which  are  four  papillae.  The  female 
has  a  tubular  uterus  and  a  tubular  ovary  in  the  posterior  half  of  the 
body. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     579 

d.  Rhabdonema.  Strongyloides.  Under  rhabdonema  intestinale  we 
now  include  two  small  nematodes,  which  were  termed  anguillula  intes- 
tinalis  and  A.  stercoralis,  and  which  are  probably  one  and  the  same. 
They  are  found  in  the  stools  of  cases  of  endemic  diarrhoea  of  hot  coun- 
tries. Usually  the  young  embryos,  which  have  developed  in  the  intes- 
tinal canal,  are  rejected  with  the  stools.  These  sexually  mature 
embryos  are  0.8  to  1.2  mm.  long,  male  and  female  respectively. 
They  are  round  and  have  a  cone-shaped  head.  There  are  two  jaws 
and  two  teeth  in  each.  The  adult  worm  is  about  2.2  mm.  long  and 
0.04  mm.  thick.  The  mouth  has  three  lips.  The  vulva  is  at  the  be- 
ginning of  the  posterior  third.  The  eggs  might  be  easily  confounded 
with  those  of  the  ankylostomum  duodenale,  but  are  somewhat  more 
pointed,  and  larger.  The  rhabdonema  infests  the  small  intestine,  and 
is  frequently  found  in  connection  with  ankylostoma. 

Echinococcus  hooklets  and  portions  of  the  striated  cyst-wall  have 
been  found  in  the  faeces.  The  rupture  of  a  hydatid  cyst  into  the 
intestine  may  be  discovered  when  the  above  structures  are  found — 
pointing  to  a  cyst  in  the  abdominal  cavity. 

B.  Vegetable  Parasites.  We  find  both  (I.)  pathogenic  and  (II.) 
non-pathogenic  vegetable  parasites  in  the  fasces.  The  latter  we  have 
classed  as  (1)  moulds,  (2)  yeasts,  and  (3)  fission -fungi. 

1.  Moulds.  The  only  mould  found  in  the  stools  is  the  thrush  fun- 
gus, when  children  are  the  subjects  of  thrush  in  the  mouth.  It  is  of 
very  rare  occurrence  in  the  fasces  and  has  no  special  clinical  import. 

2.  Yeasts.  In  all  faeces,  in  health  or  disease,  yeast  fungi  exist. 
They  are  most  numerous  in  acid  stools.  They  are  round  or  ovoid  and 
usually  occur  in  groups.  They  stain  dark  brown  with  a  solution  of 
iodine  and  iodide  of  potash,  while  apparently  similar  cells  become 
violet  or  blue  with  the  same  dye. 

3.  Fission-fungi.  Bacteria  are  found  in  greatest  numbers  in  the 
faeces,  chiefly  as  bacilli,  micrococci  and  spirilla.  They  may  be  grouped 
as  torulae  or  sarcinae.  They  present  active  movement  and  may  be  sep- 
arate or  in  colonies.  The  bacillus  coli  communis  (B.  termo)  is  the  most 
frequent  form  met  with,  both  in  health  and  disease.  It  is  not  yet 
determined  what  relations  it  holds  to  normal  and  abnormal  conditions,, 
or  what  is  the  true  relationship  between  it  and  certain  other  bacteria. 
B.  subtilis  is  another  bacterium  found  both  in  health  and  disease.  As- 
above  stated,  there  are  various  organisms  which  stain  brown  with  iodo- 
potassic-iodicle  solution,  and  others  which  become  blue  with  the  same 
dye.  Von  Jaksch  has  studied  these  latter  closely.  They  take  various 
forms,  as  long  or  short  rods,  and  take  different  shades  of  blue  or  violet. 
One  of  them  is  the  Clostridium  butyricum  of  Nothnagel.  It  occurs 
as  large  round  cells,  like  yeast  fungi,  and  stains  like  the  tubercle  bacilli 
with  the  Ziehl-Neelsen  fluid.  Von  Jaksch  finds  those  fungi  in  greater 
abundance  in  intestinal  catarrh.  They  are  present  in  both  acid  and 
alkaline  stools. 

Bacillus  Coli  Communis  has  been  found  in  the  blood,  various 
organs,  faeces  of  cholera  patients,  in  healthy  faeces,  in  the  air,  and  in 
putrefying  infusions  ;  it  can  also  be  found  in  the  peritoneal  exudate 
in  most  cases  of  peritonitis. 


580  SPECIAL  DIAGNOSIS. 

Morphology.  A  bacillus,  4  to  Q/j.  by  2  to  3//,  with  rounded  ends, 
sometimes  in  cultures  a  short  oval.  Five  or  more  filaments  have  been 
observed. 

Biological  Properties.  Aerobic  ;  facultative  anaerobic  ;  non-lique- 
fying ;  as  a  rule,  non-motile. 

Growth.  On  gelatin  plates  the  colonies  vary  very  much.  The  deep 
colonies  are  transparent,  straw  color  to  dark  brown,  or  may  be  granular 
and  opaque.  The  surface-colonies  are  large  and  spherical,  centre  dark 
brown,  edges  transparent.  In  stab-cultures  the  surface-growth  is  thin 
and  dry.  There  is  abundant  growth  along  punctures,  which  is  white 
by  reflected,  but  amber  by  transmitted  light;  sometimes  moss  like  tufts 
are  seen.  On  potato  a  soft,  shining,  brownish-yellow  layer  grows. 
Stains  with  anilines,  but  not  by  Gram's  method.  Injected  in  guinea- 
pigs  it  produces  fever,  diarrhoea,  and  collapse.  Injected  into  the 
abdomen  of  rabbits  it  causes  a  typical  peritonitis. 

Pathogenic  Fungi.  Spirillum  Cholera  Asiatics.  The  Comma- 
bacillus.  The  comma-bacillus  of  Koch  is  the  specific  causative  agent 
of  cholera.     In  a  disease  so  widespread  in  times  of  epidemics,  and  so 

fatal,  it  is  of  great  importance  to 

Flf?-  m  be  able  to  recognize  the  bacterium 

/  I     .  that  produces  it.     Works  on  bacte- 

t   J I    I  I  !  I  riology  give  a  fuller  study  than  is 

il   A'"*'  ct  "*  ''-•' <'°' >  i  '  permitted  here,  and  should  be  con- 

I \        '?*?'' ?'  !    '*   r  suited.    This  is  more  especially  true 

I  -J?  f  £"S~*     't((^J|  I  because,  while  the  bacilli,  as  found 

ii    !\''''\j  \}'*j       v\i    \(  in.  the  stools,  can  be  stained  quite 

\\\  '*'\)))'i      ''    *  WpL  \  easily,  and  may  be  recognized  by 

lljmrV^  ~<f  iif»Q%  \     !  expert  microscopists,  in  the  great 

a  }i$''/*f  ">  %'\J)    ;7''V  majority  of  cases  their  recognition 

^i\jnim..i*J~\\'*3>\*-\\\  is  only  effected  bv  bacteriological 

i*  J'ffl)KyJ  1/jLti  j)  examination.   They  have  no  specific 

I'^y'*''1  f  J\  "j V  'hy  J  \\  relation  to  dyes,  as  have  tubercle 

,J/j  >)   ,J  i'^jI  \hK\  bacilli.     The  cholera  bacillus  is  a 


*•      i!     >i\{/i''ll\  '  short,  more  or  less  bent  rod,  both 

'      I J    ■  j  )  1 1  shorter  and  thicker  than  the  tuber- 

/"  cle  bacillus,  and  generally  shaped 

Cholera  spirilla  grown  on  moist  linen.  X600.       Hke  a  CQmma>    T}         ^  ^^  f()imd 
(After  Koch.)     Cultivated  irom  the  dejections  .  i  -i     1      ■    ■ 

after  two  days.  placed  end  to  end,  and  thus  form 

a  curve  like  a  spiral.  They  are  al- 
ways present  in  the  stools  of  cholera  patients  and  sometimes  in  the 
vomit.  They  are  particularly  abundant  in  the  mucous  floccules  of  the 
rice-water  discharges,  and  can  be  obtained  from  the  linen  soiled  by  the 
same.  Cover-slip  preparations  are  made  from  these  portions  by  placing 
a  uniform  film  on  the  slip,  drying  it.  in  the  air,  and  then  passing  it 
through  the  flame  of  a  Bunsen  burner  or  spirit-iamp. 

The  spirillum,  or  so-called  "  comma-bacillus,"  consists  of  a  slightly 
curved  rod,  with  rounded  ends,  0.8  to  2/u.  long  by  0.3  to  0.4//  broad. 
It  is  usually  slightly  curved  like  a  comma,  but  may  form  a  half-circle, 
or  two  may  be  joined  like  an  S.  Under  certain  circumstances  they 
grow  out  into  long  spiral  threads.     By  Loftier' s  method  a  single  flagel- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.    581 

lum  is  found  on  the  rods.  It  stains  with  anliines,  but  slowly.  An 
aqueous  solution  of  fuchsin  is  best  (see  Plate  II.,  Fig.  3,  a  ;  and 
Fig.  109). 

Biological  Properties.     Aerobic  (fac.  anaerobic),  motile,  liquefying. 

Growth.  Grows  in  ordinary  media  at  room  temperature  ;  faster  in 
oven.  Does  not  grow  except  between  14°  to  42°  C.  Gelatin  -plates : 
At  the  end  of  twenty-four  hours  small  white  colonies  appear  deep  in 
the  gelatin.  These  grow  toward  the  surface  and  liquefy  the  gelatin  in 
a  funnel-form,  which  gradually  deepens,  and  at  the  bottom  of  the 
colony  is  seen  as  a  small  white  mass.  Under  low  power  the  colony 
is  white  or  pale  yellow,  margins  uneven,  texture  granular,  surface 
looks  as  if  covered  with  bits  of  glass.  When  liquefaction  begins  a 
dim  halo  forms  about  the  colony,  which  by  transmitted  light  is  roseate 
in  hue. 

Stab-cultures  in  Nutrient  Gelatin.  Develops  all  along  the  puncture, 
liquefaction  beginning  near  the  surface,  forming  a  funnel  which  en- 
larges, and  finally  the  gelatin  almost  entirely  liquefies  (see  Fig.  110). 


Fig.  110. 


Fig.  111. 


Cholera  spirilla.    Tube-cultivations. 

(FLttGGE.) 

a,  after  two  days  ;  b,  after  four  days. 


Kinkier  and  Prior's  comma-bacillus. 

Cultivation  in  gelatin. 

c,  two  days  ;  d,  four  days  old. 


On  potato  a  thin,  transparent  grayish-brown  layer.  Milk,  bouillon, 
blood-serum,  are  all  favorable.  In  media  with  other  bacteria  it  soon 
dies.  Death-point,  52°  5'.  In  moisture  it  retains  vitality  for  mouths, 
but  is  killed  by  drying. 

A  test  for  this  bacterium  is  the  development  of  a  purplish-red  color 
on  adding  pure  H2S04  to  a  culture  in  nutrient  gelatin. 

To  determine  its  presence  in  the  shortest  time  inoculate  diluted 
bouillon.  After  ten  to  twelve  hours  a  wrinkled  film  has  formed. 
Make  another  culture  in  the  same  way  from  this,  then  inoculate  gelatin 
plates,  and  use  color-test  on  these.     Several  toxin-  have  been  isolated. 


582  SPECIAL  DIAGNOSIS. 

The  bacillus  of  cholera  nostras  and  one  found  in  cheese  by  Deneke 
resemble  the  comma-bacillus  in  shape,  though  somewhat  larger,  but 
they  have  bacteriological  peculiarities  by  which  they  can  be  differen- 
tiated. 

Spirillum  Cholera  Xostras  Morphology.  Longer  and  thicker; 
central  part  thicker  than  ends.     Stains  same  as  above. 

Biological  Properties.  Culture.  A  thick,  stocking-like  funnel  of 
liquefaction  instead  of  a  fine,  straight  funnel  (see  Fig.  111). 

Typhoid  Fever  Bacillus.  This  bacillus  is  present  in  the  stools 
of  typhoid  fever  patients,  but  cannot  be  directly  differentiated  by 
microscopic  examination  alone,  either  when  stained  or  unstained.  It 
is  necessary  for  its  detection  to  make  pure  cultures  according  to  bac- 
teriological methods.  The  bacillus  is  about  as  long  as  the  tubercle 
bacillus,  but  much  thicker,  being  one  third  as  thick  as  it  is  long.  The 
ends  are  rounded.  It  is  best  stained  by  concentrated  aqueous  solutions 
of  methylene-blue,  the  dried  preparations  on  the  cover-slip  being  pre- 
pared as  above  (see  Plate  II.,  Fig.  6,  b  ;  and  Typhoid  Fever). 

Tubercle  Bacillus.  The  bacillus  of  tuberculosis  is  frequently 
found  in  the  faeces  of  persons  suffering  from  intestinal  tuberculosis  and 
occasionally  in  the  faeces  of  cases  of  pulmonary  tuberculosis,  when 
sputum  containing  bacilli  has  been  swallowed.  When  tubercle  bacilli 
are  constantly  found  in  the  faeces,  and  in  large  quantities,  it  points  to 
the  former  condition  almost  to  a  certainty.  They  are  detected  in  the 
same  manner  in  the  sputum. 

Bacilli  of  Booker.  No  less  than  nine  bacilli  have  been  described 
by  Booker.  Each  of  these  has  been  found  by  him  in  cases  of  diarrhoea 
in  children.  Seven  of  these  resemble  very  closely  bacillus  coli  com- 
munis. Bacillus  A  is  a  bacillus  with  rounded  ends,  3-4//.  by  0.7//. 
It  is  aerobic  and  facultative  anaerobic,  liquefying,  and  motile.  Colo- 
nies on  agar  and  potato  are  dirty  brown.  On  gelatin  they  liquefy  too 
soon  to  show  characteristic  form. 

The  bacillus  is  found  in  the  stools  of  cholera  infantum. 

Chemical  Examination.  The  chemical  examination  of  the  faeces 
is  of  but  slight  clinical  value.  Mucin  and  albumin  are  normally 
present ;  peptones  in  different  diseases  (Von  Jaksch).  Among  the 
acids  to  be  found  are  bile-acids,  volatile  and  fatty  acids,  formic,  acetic, 
butyric,  and  propionic  acids  ;  while  phenol,  indol,  skatol,  cholesterin, 
and  fats  are  always  present,  according  to  the  same  author.  They  will 
not  aid  in  diagnosis. 

The  normal  coloring-matter  of  the  faeces  is  urobilin  ;  its  presence 
is  shown  by  the  proper  tests.  As  before  stated,  bile-pigment  never 
occurs  in  the  faeces  in  health  ;  it  is  present  when  there  is  catarrh  of 
the  small  intestine.  Blood-pigment  is.  usually  in  the  form  of  haematin. 
As  might  be  expected,  ptomaines  have  been  obtained  from  the  faeces 
of  certain  diseases  caused  by  fungi. 


Intestinal  Indigestion. 

n  is  said  to  be  due  to  altei 
of  the  bile,  the  pancreatic,  or  the  intestinal  secretion.      It  is  almost 


Intestinal  indigestion  is  said  to  be  due  to  alterations  in  or  diminution 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     583 

always  attended  by  gastric  indigestion,  and  may  not  readily  be  distin- 
guished from  it.  Acute  intestinal  indigestion  is  due  to  the  irritation  of 
food  not  properly  digested  in  the  stomach.  It  is  attended  with  colic, 
flatulency,  and  borborygmi.  Some  fever  may  develop,  and  diarrhoea 
may  ensue.  In  the  mild  forms  the  tongue  is  coated,  there  are  loss  of 
appetite  and  some  general  pains.  There  is  epigastric  distress  or  pain 
in  the  right  upper  quadrant.  There  are  flatulency  and  constipation. 
The  stools  are  often  clay-colored,  or  may  not  be  changed.  Slight 
jaundice  occurs,  and  there  is  an  abundance  of  lithates  in  the  urine. 
Accompanying  gastric  indigestion  modifies  the  symptoms  slightly. 

The  symptoms  are  more  marked  and  pronounced  in  chronic  intestinal 
indigestion.  The  local  symptoms  are  as  follows  :  Pain  which  begins 
from  two  to  six  hours  after  eating.  It  may  be  complained  of  in  the 
region  of  the  liver  or  below  the  sternum.  It  is  usually  seated  in  the 
umbilical  region.  It  is  dull  and  continues  two  or  three  hours,  or  until 
the  next  meal  is  taken.  There  is  some  tenderness.  With  the  pain 
there  are  tympanites,  borborygmi,  and  a  sense  of  fulness  in  the  abdo- 
men; the  bowels  are  constipated,  and  the  stools  are  hard  and  dry. 
The  constipation  alternates  with  diarrhoea,  and  undigested  particles  of 
food  are  passed.  The  appetite  is  not  lost,  but  is  variable.  Hemor- 
rhoids are  often  present.  The  general  symptoms  are  marked,  and  are 
referred  to  the  nervous  system  and  the  condition  of  the  blood.  There 
are  great  depression  and  hypochondriasis.  The  patients  sleep  badly, 
suffer  from  bad  dreams  and  tinnitus  aurium  ;  there  are  spots  before 
the  eyes  and  more  or  less  constant  headache.  They  complain  of  pain 
in  the  back  and  limbs,  and  hyperesthesias  or  anaesthesias  are  present. 
There  is  inaptitude  for  mental  exertion.  Frequently  the  patient  lias 
sudden  attacks,  apparently  due  to  toxins,  as  sudden  fainting  followed 
by  collapse,  or  vertigo.  During  these  attacks  there  are  great  palpita- 
tion and  tachycardia.  The  extremities  are  cold,  and  there  are 
cold  sweats  over  the  body.  Independently  of  the  attacks,  the  patient 
is  subject  to  palpitation  and  some  dyspnoea.  The  urine  is  always 
high-colored,  acid  in  reaction,  and  full  of  urates  and  uric  acid. 
Oxalate  of  lime  may  be  present,  and  the  albuminuria  of  uric  acid 
occurs.  The  patient  is  anaemic  ;  the  anaemia  develops  early.  There 
is  some  emaciation  ;  in  some  cases. the  emaciation  is  rapid.  The  com- 
plexion is  sallow.  If  there  is  an  abundance  of  oxalates,  the  patient 
complains  of  weight  and  heaviness  about  the  loins.  The  stools  may 
contain  fat,  indicating  probable  pancreatic  disease,  if  fatty  food  has 
been  ingested.  On  the  other  hand,  with  loss  of  appetite,  furred  tongue, 
frontal  headache,  and  drowsiness,  the  stools  may  be  clay-colored  and 
the  bowels  costive  ;  apparently  the  bile  is  at  fault. 

Acute  Intestinal  Catarrh. 

Cause.  Exposure  to  cold  or  the  direct  irritation  of  mechanical  or 
chemical  substances  within  the  intestine.  Irritating  food  that  is  not 
digested,  or  that  cannot  be  digested  because  of  the  quantity;  spoiled 
meats  aud  unripe  fruit  usually  excite  an  attack.  Water  saturated  with 
impurities,  or  such  as  the  individual  is  not  accustomed  to,  may  excite 


584  SPECIAL  DIAGNOSIS. 

an  attack.  Strangers  in  a  new  locality  are  frequently  subject  to  a 
diarrhoea  until  accustomed  to  the  drinking-water,  which  in  the  native 
does  not  excite  catarrh.  Toxic  substances,  as  poisons  or  drugs,  or 
toxic  substances  the  result  of  putrefaction,  as  ptomaines,  are  frequent 
exciting  causes.  Extension  of  inflammation  from  neighboring  struc- 
tures by  infection,  as  in  peritonitis,  sets  up  a  catarrh.  Local  diseases 
of  the  intestine,  as  ileus,  intussusception,  hernia,  and  ulcers  of  all 
forms,  are  attended  by  catarrh  of  the  intestine.  It  also  occurs  in 
cachectic  states  of  the  system,  as  cancer,  ansemia,  and  Bright' s  disease. 
In  diseases  of  the  heart  and  bloodvessels,  or  of  the  liver  and  spleen, 
where  the  disturbance  of  the  circulation  causes  a  congestion,  catarrhal 
inflammation  occurs.  It  is  of  common  occurrence  in  the  infectious 
diseases,  and  particularly  in  septicaemia  and  pyaemia. 

Symptoms.  Diarrhoea  is  the  chief  symptom,  varying  with  the  cause 
and  the  extent  of  the  catarrhal  inflammation.  The  stools  differ  in 
frequency  and  in  color,  as  has  been  previously  indicated  in  the  various 
types.  They  contain  undigested  matter;  sometimes  worms.  Colicky 
pains  about  the  umbilicus,  with  borborygmi  and  frequent  desire  to 
go  to  stool,  attend  each  evacuation.  The  fever  is  of  the  remittent 
type,  and  is  attended  with  some  prostration.  The  urine  is  scanty  and 
high-colored.  The  symptoms  vary  somewhat  with  the  location  of  the 
inflammation,  although  the  exact  locality  cannot  be  distinctly  defined. 
The  symptoms  of  proctitis,  pain  with  tormina  and  tenesmus,  do,  how- 
ever, enable  the  localization  to  be  made  to  that  portion  of  the  bowel. 
These  are  more  common  than  in  inflammation  apparently  limited  to 
the  small  intestine,  while  in  colitis  the  violence  of  the  rectal  symp- 
toms stands  between  enteritis  and  proctitis. 

The  diagnosis  of  acute  intestinal  catarrh  is  not  difficult.  It  is  more 
difficult  to  determine  the  actual  cause.  If  the  attack  occurs  suddenly 
after  the  eating  of  improper  food,  or  the  drinking  of  impure  water,  the 
irritation  is  probably  due  to  that  cause,  and  may  be  determined  by  the 
nature  of  the  f seces.  If  they  contain  undigested  food,  the  diarrhoea  is 
probably  due  to  indigestion.  Catarrh  from  cold  usually  follows  expo- 
sure, and  is  generally  not  very  severe.  To  estimate  the  cause  from 
poison  or  drugs  the  condition  of  the  rest  of  the  intestinal  tract  must  be 
investigated  and  other  symptoms  of  the  effects  of  drugs  must  be 
inquired  for.  In  arsenical  poisoning  there  is  always  vomiting  and  the 
discharges  are  of  a  choleraic  nature.  Collapse  rapidly  ensues.  The 
other  symptoms  of  arsenical  poisoning  must  be  inquired  for  and  the 
history  of  exposure,  if  possible,  ascertained.  The  intestinal  catarrh 
due  to  infections  diseases  is  attended  by  the  symptoms  due  to  the 
respective  affections,  each  of  which  is  usually  readily  recognized.  It 
may  be  necessary  to  resort  to  a  bacteriological  examination  of  the  fseoes. 
The  intestinal  catarrh  which  occurs  on  account  of  local  disease  of  the 
bowel,  as  hernia,  stricture,  etc.,  is  preceded  or  attended  by  the  local 
symptoms  of  these  diseases.  In  like  manner  we  judge  of  the  nature 
of  the  diarrhoea  that  occurs  in  the  course  of  tuberculosis  or  syphilis, 
and  in  the  course  of  organic  heart  disease  or  of  liver  disease.  In  each 
instance  the  possible  influence  of  morbid  processes  present  in  other 
structures  must  be  very  carefully  estimated. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     585 

The  Varieties  of  Acute  Intestinal  Catarrh.  Divisions  have 
been  made  in  accordance  with  the  symptoms  which  distinguish  the 
various  localities  of  the  intestine  in  which  the  inflammation  is  most 
marked. 

Catarrh  of  the  Duodenum.  This  partakes  of  the  nature  and  has  the 
symptoms  of  gastro-intestinal  catarrh  in  a  mild  degree,  and  is  charac- 
terized by  the  occurrence  of  jaundice  due  to  catarrhal  inflammation  of 
the  biliary  passages. . 

The  Small  Intestine.  Colicky  pains  and  rumbling  are  experienced. 
There  is  usually  gastritis  at  the  same  time.  The  fseces  are  mixed  with 
mucus.    Over  the  right  lower  quadrant  there  is  tenderness  on  pressure. 

Ccecum.  Pain  in  the  right  lower  quadrant  with  tumor,  dulness  on 
percussion,  and  tenderness  are  present  (see  Typhlitis). 

Colitis.  The  large  intestine  is  most  frequently  affected.  Pain  and 
tenderness  along  the  course  of  the  bowel.  The  evacuations  contain 
mucus  ;  there  is  tenesmus. 

The  Rectum.  Proctitis  gives  rise  frequently  to  small  stools,  tenes- 
mus, pain  in  the  left  lower  quadrant,  with  tenderness  about  the  anus, 
and  spasm  of  the  sphincter.  There  are  considerable  mucus  and  blood 
in  the  passages. 

Cholera  Infantum.  This  affection  occurs  in  children  during  the 
hot  season.  It  is  promoted  by  bad  hygienic  surroundings  and  is 
due  to  improper  milk  or  food.  At  first  there  is  catarrhal  diarrhoea. 
This  may  continue  for  twenty-four  hours,  then  vomiting  and  diarrhoea 
ensue.  The  stools  are  liquid  and  large  in  amount.  At  first  they  may 
contain  milk-curds.  The  vomiting  is  excited  by  anything  taken  into 
the  mouth,  or  by  odors,  or  by  movement  of  the  little  patient.  The 
watery  discharges  are  almost  constant.  They  may  be  preceded  by 
greenish  or  yellowish-green  stools  for  twenty-four  hours.  Stools  are 
acid  in  reaction,  and  their  odor  is  sour.  At  first  there  is  colicky  pain, 
but  when  the  watery  discharges  begin  there  is  only  a  little  tenesmus. 
The  abdomen  is  at  first  distended  with  gas,  but  soon  becomes  retracted. 
The  fseces  irritate  the  skin  and  cause  eczema.  The  rectum  may  become 
prolapsed.  In  a  short  time,  twenty-four  hours  or  even  less,  collapse 
ensues.  Previous  to  the  collapse  the  skin  is  hot  and  dry,  patient  rest- 
less, the  thirst  intense,  the  mouth  dry.  The  body-temperature  is  103° 
to  104°.  With  collapse  the  extremities  become  cold,  the  skin  cool. 
The  axillary  temperature  is  lowered  and  the  rectal  temperature  increased 
to  105°  to  106°.  The  restlessness  continues,  the  fontanelles  become 
depressed,  the  eyes  sunken,  the  face  pinched,  the  brows  drawn.  The 
urine  diminishes  in  amount  or  may  disappear  entirely.  Brain  symp- 
toms ensue.  So-called  hydrocephalic!  symptoms  follow — rolling  of 
the  head,  strabismus,  turning  in  of  the  thumbs,  and,  later,  convulsions. 
Stupor  followed  by  coma  develops  in  the  fatal  cases.  If  the  patient 
does  not  die  in  collapse,  marasmus  develops  ;  ulceration  of  the  cornea 
may  take  place  ;  there  are  oedema  and  blood  extravasation  under  the 
skin.  The  child  emaciates  and  withers.  On  account  of  the  weals- 
heart  and  exhaustion  pulmonary  atelectasis  or  broncho-pneumonia 
may  occur.  The  age,  the  season,  the  presence  of  catarrh,  with  col- 
lapse and  other  symptoms,  render  the  diagnosis  easy. 


586  SPECIAL  DIAGNOSIS. 

Entero-COLITIS.  In  entero-colitis  the  more  intense  inflammation 
succeeds  a  mild  intestinal  catarrh.  There  are  increased  languor,  great 
fretfulness,  and  fever.  The  early  catarrh  is  attended  by  green  acid 
stools,  with  lumps  of  casein.  The  tongue  is  furred  and  moist  at  first. 
It  soon  becomes  red  and  dry  ;  vomiting  ensues.  The  stools  are  offen- 
sive and  increase  in  frequency,  and,  in  addition  to  the  appearance  first 
indicated,  contain  mucus  and  blood.  Death  may  take  place  within 
the  first  week  on  account  of  exhaustion  from  the  vomiting  and  diar- 
rhoea. If  the  disease  is  protracted,  it  is  attended  by  great  wasting, 
symptoms  of  hydrocephalus,  skin  eruptions,  hypostatic  pneumonia, 
and  extremely  weak,  feeble  circulation. 

Acute  Dysentery.  The  term  dysentery  is  applied  to  an  inflam- 
mation of  the  intestinal  tract,  chiefly  the  colon,  which  is  attended  by 
the  symptoms  of  intestinal  catarrh  in  intense  degree,  with  mucous  and 
bloody  discharges  and  the  general  symptoms  of  fever  and  prostra- 
tion, followed  by  extreme  exhaustion,  and  at  times  the  occurrence 
of  abscesses  in  the  portal  circulation,  or  of  paralysis,  arthritis,  nephritis, 
or  profound  anaemia.  It  was  formerly  thought  to  be  an  epidemic, 
mildly  contagious  disease.  Although  of  frequent  occurrence  sporad- 
ically, it  is  especially  common  in  jails  and  institutions,  in  camps,  or 
where  people  are  crowded  together,  when  at  the  same  time  hygienic 
conditions  are  most  unfavorable.  It  usually  occurs  in  the  summer  or 
fall,  and  is  attributed  to  the  drinking  of  impure  water.  A  form  most 
common  in  the  tropics  is  called  tropical  dysentery.  Recent  investiga- 
tions have  shown  that  catarrhal  dysentery  due  to  the  above-mentioned 
circumstances  may  occur,  and  that  in  addition  "tropical"  dysentery, 
which  is  not  confined  to  the  tropics,  is  associated  with  inflammation 
and  ulceration  of  the  bowel,  attended  by  the  amoeba  dysenteric  or 
A.  coli. 

Catarrhal  Dysentery  may  be  limited  to  simple  inflammation  of  the 
intestine,  or  may  be  followed  by  ulceration.  Its  first  symptoms  are 
those  of  intestinal  catarrh.  There  is  indigestion,  with  loss  of  appetite, 
perhaps  vomiting,  and  slight  diarrhoea.  These  symptoms  may  be  the 
immediate  effect  of  the  diarrhoea.  At  the  end  of  three  or  four  days 
a  chill  may  take  place,  showing  the  setting  in  of  an  infection.  The 
diarrhoea  is  attended  by  pain,  at  first  seated  around  the  umbilicus  ;  it 
then  becomes  marked  in  the  course  of  the  colon.  The  movements 
are  frequent,  preceded  by  constant  desire,  and  attended  by  extreme 
tenesmus.  The  stools,  which  were  first  fsecal  and  fluid,  soon  become 
scanty,  and  consist  almost  entirely  of  mucus  and  blood.  The  symp- 
toms of  local  proctitis  are  intense  ;  there  is  a  sensation  of  a  hot  mass 
in  the  rectum.  There  may  be  strangury,  and  prolapse  of  the  anus 
may  ensue. 

With  the  acute  pain  and  frequent  evacuations  the  skin  is  hot  and 
dry  ;  thirst,  nausea,  and  occasionally  vomiting  occur.  The  tempera- 
ture continues  at  about  103°;  the  pulse  is  rapid.  The  patient  is  weak 
and  restless  ;  the  tongue  is  red  and  raw. 

If  the  disease  is  severe  from  the  start,  or  the  course  is  unfavorable, 
stools  may  contain  pure  blood,  or  they  may  be  dark  in  color,  and  con- 
tain shreds  of  membrane.    Pain  and  tenesmus  disappear,  and  the  evac- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     587 

nations  become  constant  or  involuntary.  Restlessness  is  aggravated  ; 
the  extremities  become  cold  ;  mild  delirium  sets  in.  The  tossing  and 
restlessness  are  quite  characteristic,  and  are  attended  by  sighing  and 
some  dyspnoea.  The  pulse  is  rapid  and  feeble  ;  the  heart-sounds  are 
weakened  ;  the  tongue  becomes  dry  and  brown,  the  mouth  is  parched, 
and  thirst  is  intense ;  ulcers  develop  in  the  mouth  and  sordes  collect 
around  the  teeth.  The  delirium  increases  to  stupor,  and  from  that  to 
coma.  The  urine,  at  first  high-colored  and  scanty,  becomes  bloody  and 
contains  albumin  and  casts.  Although  the  fever  continues  during  this 
stage,  the  extremities  become  cool,  perspiration  breaks  out  over  the  fore- 
head, and,  instead  of  typhoid  symptoms,  the  symptoms  of  collapse 
may  ensue.  If  the  disease  is  prolonged  and  the  bowels  are  controlled, 
the  symptoms  of  pyaemia  may  develop. 

The  anaemia  that  ensues  is  extreme,  and  there  is  great  wasting. 
Convalescence  is  slow  and  may  be  attended  by  chronic  diarrhoea. 
Before  it  is  established  ulcers  of  the  skin  may  form  on  various  parts 
of  the  surface  of  the  body.  Arthritis  is  of  common  occurrence,  and 
paralysis  may  occur  during  convalescence  on  account  of  peripheral 
neuritis.  Chronic  dysentery  may  succeed  the  acute.  It  is  thus  seen 
that  the  attacks  may  be  of  moderate  severity  or  extremely  grave  ;  dur- 
ing the  course  of  the  latter  gangrene  of  the  lower  bowel  may  take  place. 

Amcebic  Dysentery.  This  differs  from  catarrhal  forms  of  dysen- 
tery in  many  respects.  The  onset  may  be  abrupt  or  gradual,  as  in  the 
previous  form,  with  symptoms  of  intestinal  catarrh.  In  most  of  the 
cases  a  frequent  and  painless  diarrhoea  follows  a  period  of  slight  ill 
health.  The  diarrhoea  alternates  with  short  periods  of  constipation  ; 
the  stools  are  watery  and  contain  mucus,  but  no  blood.  The  course  of 
the  disease  is  irregular  There  may  be  intermissions  and  exacerbations 
of  the  diarrhoea  without  obvious  cause.  It  may  rapidly  pass  from  oue 
grade  to  another,  or  become  chronic.  One  form  is  the  gangrenous, 
which  may  scarcely  be  appreciated  by  the  symptoms  until  the  autopsy 
shows  it  to  have  been  present.  True  relapses  are  common,  and  the 
tendency  to  chronicity  is  very  great.  The  milder  cases  are  attended 
by  weakness,  emaciation,  and  pallor  ;  the  expression  is  dull  ;  the  skin 
is  dry  and  sallow;  the  tongue  pale,  flabby,  and  moist,  slightly  furred; 
the  abdomen  is  normal  or  retracted  ;  the  temperature  does  not  rise 
above  100°,  and  the  pulse  ranges  from  70  to  90.  Sleep  is  disturbed 
by  frequent  evacuations  of  the  bowels.  In  the  grave  form  the  face  is 
drawn,  or  cyanosed  or  flushed,  the  expression  anxious  ;  the  mind  is 
clear.  Anorexia,  intense  thirst,  and  sleeplessness  are  present.  The 
abdomen  is  greatly  retracted,  and  there  may  be  free  sweating.  The 
temperature  is  normal  or  subnormal,  the  pulse  small  and  rapid.  Pro- 
gressive anaemia  and  loss  of  flesh  are  prominent  and  dominate  the 
intestinal  symptoms.  The  skin  is  dry  and  harsh,  and  of  a  dull  greenish- 
yellow  color  if  the  cases  are  protracted. 

The  special  features  of  amoebic  dysentery  are:  1.  The  anosmia. 
This  is  due  to  diminution  of  the  red  cells  and  the  hemoglobin,  first, 
because  of  the  action  of  the  amoebae  upon  the  red  blood-corpuscles, 
which  they  destroy  ;  second,  the  direct  loss  of  blood  ;  and,  third,  mal- 
nutrition.     The  first  is  the  most  prominent. 


588  SPECIAL  DIAGNOSIS. 

2.  Diarrhoea  rnay  be  the  only  feature  of  the  disease.  It  is  charac- 
terized by  great  variation  in  character  and  frequency  in  all  grades  and 
during  different  periods  of  the  disease.  Intermissions  and  exacerba- 
tions may  be  observed  at  any  time.  The  latter  begin  suddenly,  and 
subside  in  the  same  manner.  They  may  last  from  two  to  ten  days. 
The  intermissions  continue  from  one  day  to  three  weeks,  during  which 
the  faeces  are  soft,  but  contain  mucus.  Councilman  and  Lafleur  have 
observed  this  periodicity  to  be  most  marked  in  cases  complicated  with 
hepatic  abscess. 

3.  The  Stool*.  The  stools  are  extremely  variable  according  to  the 
severity  of  the  ulceration,  and  also  vary  in  number  and  character  from 
day  to  day  in  individual  cases.  In  the  gangrenous  form  they  number 
thirty  or  forty  in  twenty-four  hours  at  first,  then  decline,  so  that  toward 
the  end  of  fatal  cases  but  three  or  four  take  place.  At  first  the  move- 
ments are  small  and  consist  of  mucus  with  more  or  less  bright  blood  and 
small  faecal  masses.  As  ulceration  advances  the  stools  change,  they 
become  more  copious  and  watery,  faeces  are  absent,  blood  is  not  so 
frequent.  Shreddy  masses  of  grayish  or  yellow  color,  mixed  with 
mucus,  appear.  If  there  is  sloughing,  they  become  greenish  or  grayish, 
resembling  spinach,  or  reddish-brown  and  very  liquid  or  pultaceous. 
The  odor  is  penetrating  and  offensive.  Shreddy  masses  of  necrotic 
tissue  are  discharged.  Gray  liquid  movemeuts,  somewhat  slimy,  con- 
tain more  pus  than  the  others.  Small  opaque,  or  translucent,  gelat- 
inous grayish  masses,  one  to  three  cubic  millimetres  in  diameter,  are 
found  in  the  stools. 

In  the  more  moderate  types  the  stools  at  the  outset  are  like  those  of 
gangrenous  dysentery  if  the  attack  is  abrupt.  If  gradual,  the  stools 
are  faecal,  liquid,  containing  mucus  and  streaks  of  blood  and  many  of 
the  gelatinous  grayish  masses.  Stools  of  this  character  number  from 
four  to  ten  in  twenty-four  hours  ;  this  may  continue  for  weeks.  Dur- 
ing the  exacerbations  the  stools  resemble  those  of  the  second  period  of 
the  gangrenous  form.  In  chronic  dysentery  there  is  not  so  much  mucus 
or  blood,  except  in  exacerbations.  The  stools  are  of  the  consistence  of 
thin  gruel  and  have  an  earthy  or  dull-yellow  color.  Mucus  is  persistently 
present,  however,  in  the  intermissions,  when  the  stools  are  soft  and  faecal. 

The  reaction  of  dysenteric  stools  is  generally  alkaline. 

Microscopical  Examination.  In  the  mucoid  and  bloody  stools  of 
the  acute  stage  red  blood-corpuscles,  leucocytes,  and  large,  round,  or 
oval  epithelioid  cells  are  seen.  The  latter  are  often  in  groups  of  three 
or  more.  The  nucleus  is  about  the  size  of  the  red  blood-corpuscle,  the 
protoplasm  granular.  Their  outline  is  sharp.  They  may  be  taken  for 
amoebae.  They  are  non-motile  and  refract  light  less  strongly.  Cerco- 
monas  intedina/is  is  present,  but  bacteria  are  not  abundant.  In  the 
later  periods  the  cell-elements  are  less  numerous;  shreddy  and  muscular 
detritus  and  bacteria  are  observed,  with  elastic-tissue  fibres.  Charcot's 
crystals  and  phosphates  are  seen.  In  chronic  dysentery  the  cell-ele- 
ments are  still  fewer  and  amoebae  are  easily  detected. 

Amoeba.  Amoebae  are  found  at  all  periods  of  the  disease.  They 
vary  in  different  cases  and  at  different  periods  in  proportion  to  the 
severity  of  the  intestinal  ulceration. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     589 

Thev  are  most  abundant  in  the  grayish-yellow  gelatinous  masses, 
next  in  the  particles  of  clear  or  opaque  mucus,  and  least  in  the  fluid 
portions  of  the  stools.  In  chronic  dysentery  they  are  found  in  all 
portious.  In  the  intermission  of  the  diarrhoea  they  may  be  found  in 
the  particles  of  mucus  adherent  to  the  fseces.  They  disappear  as 
recovery  proceeds,  although  they  may  be  seen  after  the  evacuations 
become  normal.  They  vary  in  size  and  activity.  They  are  more 
common  in  the  alkaline  and  neutral  stools.  They  are  scarce  and  are 
rarely  motile  in  acid  stools.  In  the  more  active  forms  of  the  disease 
red  corpuscles  are  seen. 

For  their  detection  the  following  should  be  observed:  F.rst,  the 
stools  should  be  passed  in  a  warm  bed-pan  and  kept  at  a  temperature 
of  30°  to  35°  C.  until  an  examination  is  made.  Second,  the  stools 
must  be  examined  before  they  become  acid.  Third,  the  gelatinous 
masses  in  the  stools  should  be  selected  for  examination.  They  contain 
amoeba?  in  greatest  abundance.  A  magnifying  power  of  four  hundred 
diameters  is  required,  although  they  may  be  seen  with  less. 

Description  of  the  Amoebae.  When  inactive  they  are  round  or  slightly 
oblong,  highly  refractive,  and  contain  vacuole-;  of  greater  or  le.-s  size. 
The  latter  are  clear,  and  vary  from  small  points  to  one-third  of  the 
diameter  of  the  areola.  The  ecto-  and  endosarc  may  or  may  not  be 
sharply  divided.  If  they  are,  the  outer  is  hyaline  or  homogeneous, 
the  inner  is  more  refractive  and  contains  vacuoles.  They  are  difficult 
to  recognize  in  this  condition,  being  mistaken  for  swollen  connective- 
tissue  cells.  The  amoebae  frequently  enclose  red  corpuscles,  pus-cells, 
blood-pigment,  bacilli,  and  micrococci.  In  a  fresh  state  the  nuclei  can- 
not be  made  out  because  they  resemble  vacuoles.  The  endosarc  is  not 
granular,  is  composed  of  a  dense  substance  and  is  highly  refracting. 
When  active  the  movement  is  characteristic.  It  may  be  slow  or  rapid, 
and  is  of  two  kinds,  a  progressive  movement  and  one  limited  to  the 
throwing  out  of  pseudopodia.  The  movements  appear  to  be  rhyth- 
mical in  some  cases,  occurring  at  regular  intervals.  The  movement 
is  sudden  and  characterized  by  change  in  form  of  the  pseudopodia. 
The  ecto-  and  endosarc  are  clearly  defined  usually.  The  pseudopodia 
are  hyaline  and  homogeneous,  like  the  ectosarc.  The  amoeba  changes 
its  position  sometimes  by  enlargement  of  the  pseudopodia,  into  which 
the  inner  contents  of  the  older  part  follow.  The  movements  are 
increased  when  the  examinations  are  made  on  the  warm  stage. 

In  catarrhal  dysentery  the  stools  are  uniform  in  character,  quantity, 
and  frequency.  The  onset  is  sudden,  and  evacuations  consist  of 
bright  blood  and  viscid,  clear  mucus  mixed  with  faecal  matter.  Soon 
they  are  composed  entirely  of  mucus  and  a  little  blood.  The  mucus 
is  viscid.  In  a  week  or  ten  days  the  mucus  changes  and  becomes 
grayish-white  in  color — is  less  blood-stained  and  brown  ;  pultaceous 
or  fluid  faecal  matter  appears  in  the  stools.  As  the  blood  and  mucus 
disappear,  formed  faeces  return.  In  the  prolonged  cases  there  are  soft, 
yellowish-brown,  or  greenish  stools  in  addition  to  the  bloody  mucoid 
stools.  The  frequency  is  greatest  at  the  onset,  and  progressively  dimin- 
ishes until  convalescence  is  established.  The  more  frequent  the  evac- 
uations the  smaller  the  size  of  the  stools.     The  mucoid  stools  are  small, 


590  SPECIAL  DIAGNOSIS. 

pultaceous,  more  bulky.  On  microscopical  examination  red  and  white 
corpuscles,  cylindrical,  epithelial,  and  oval  epithelioid  cells  are  seen. 
The  latter  are  very  characteristic,  and  occur  singly  or  in  groups.  Bac- 
teria are  more  common  as  improvement  sets  in.  In  the  pultaceous 
stools  the  cell-elements  are  scarce.  In  diphtheritic  dysentery  the  stools 
are  watery.  They  resemble  wheat-washings — evacuations  such  as  are 
described  in  cases  of  gangrenous  dysentery.  They  are  grayish-green 
or  reddish-brown  and  very  offensive.  Mucus  is  present  in  small 
amounts.  At  first  unclotted  blood  is  present,  afterward  minute  dark- 
red  clots  are  seen.  Shreddy  and  finely  divided  material,  gray  or  red- 
dish-brown in  color,  is  present,  but  there  are  no  sloughs.  The  stools 
are  not  numerous  at  first,  and  average  from  seven  to  fifteen  daily  dur- 
ing the  course  of  the  illness.  The  quantity  passed  is  small.  Cylin- 
drical epithelial  cells  are  most  abundant  on  microscopical  examination. 
Red  blood-corpuscles  and  leucocytes  are  observed,  but  fibrin  constitutes 
the  larger  portion  of  the  stool.  In  all  the  stools  bacteria  are  present 
in  great  numbers. 

Other  Symptoms  of  Amoebic  Dysentery.  Abdominal  -pain  is  con- 
stant ;  it  occurs  in  the  early  stages  of  both  forms  and  in  acute  exacer- 
bations. As  the  movements  diminish  the  pain  decreases.  In  the 
gangrenous  form  pain  also  disappears,  although  the  intensity  of  the. 
process  is  increasing.  In  chronic  cases  the  colic  is  complained  of  dur- 
ing the  exacerbations;  during  the  intervals  a  dull,  aching  or  burning 
pain  is  complained  of  in  the  upper  quadrants.  In  all  cases  the  pain 
is  cramp-like,  boring  or  burning  in  character,  and  usually  precedes 
and  accompanies  movements  of  the  bowels.  When  severe,  it  is  gen- 
eral ;  but  it  is  usually  localized  in  the  lower  abdominal  zone.  Mod- 
erate tenderness  on  pressure  is  present  in  most  cases  along  some  part 
of  the  course  of  the  large  bowel.  In  catarrhal  dysentery  tenesmus  is 
common  ;  in  the  amoebic  form  it  is  infrequent.  A  burning  sensation 
in  the  rectum  and  at  the  anus  during  and  after  the  passage  of  fasces  is 
generally  complained  of.  Nausea  and  vomiting  occur  at  the  outset 
or  at  irregular  intervals,  being  caused  by  improper  food,  or  due  to 
complications.     Hiccough  occurs  in  the  terminal  stages. 

Fever.  In  amoebic  dysentery  fever  is  not  a  prominent  feature, 
although  there  is  usually  a  moderate  rise  in  temperature.  In  the  gan- 
grenous form  it  is  normal,  or  may  be  subnormal  for  days.  Chronic 
dysentery  is  afebrile.  In  exacerbations  of  diarrhoea  slight  fever  may 
occur.  Complications  cause  a  higher  temperature.  If  fever  is  pres- 
ent it  may  be  remittent  or  intermittent  in  character,  or,  if  the  illness 
is  prolonged,  first  continuous,  then  remittent,  and  then  intermittent. 
If  the  latter,  the  usual  morning  fall  is  observed,  although  an  inverse 
temperature  may  be  present.  Rigors  occur  with  the  complications. 
Sweating  is  observed,  with  subnormal-  temperature,  in  the  gangrenous 
form.     In  cases  of  abscess  the  fever  is  intermittent  or  remittent. 

In  chronic  dysentery  the  skin  is  excessively  dry.  The  circulation 
and  respiration  are  influenced  by  the  pyrexia.  Ansemia  is  pronounced. 
When  exhaustion  ensues  the  pulse  becomes  more  feeble,  compressible 
and  rapid.  The  urine  is  albuminous,  and  often  contains  casts.  In 
the  gangrenous  form  there  may  be  retention  of  urine. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     59 1 

The  complications  of  amoebic  dysentery  are  :  1.  Hepatic  abscess, 
or  hepato-pulmonaiy  abscess.  2.  Peritonitis.  3.  Hemorrhage  from 
the  bowels. 

Abscess  may  develop  in  all  forms  and  at  any  period  of  the  disease. 
The  time  of  the  disease  at  which  it  occurs  cannot  be  determined  defi- 
nitely. In  the  subacute  cases  it  is  liable  to  develop  from  the  fourth 
to  the  twelfth  week.  The  abscess  may  develop  on  the  convex  surface 
of  the  right  lobe  of  the  liver  near  the  coronary  ligament.  lu  these 
cases  the  lung  also  becomes  involved.  Councilman  and  Lafleur  sug- 
gest that  infection  takes  place  by  the  peritoneum  (see  Abscess  of  the 
Liver). 

While  the  symptoms  of  abscess  of  the  liver  will  be  treated  under 
the  section  devoted  to  liver  disease,  it  is  important  to  note  that  hepatic 
symptoms  may  occur  in  cases  in  which,  on  account  of  the  mildness  of 
the  disease,  the  local  bowel  trouble  may  be  overlooked  entirely.  If 
the  association  of  hepatic  pain  with  fever  and  discharge  of  mucus 
from  the  bowels  is  observed,  it  is  barely  possible,  even  if  an  examina- 
tion of  the  fasces  cannot  be  made,  that  an  hepatic  abscess  is  present. 
If,  in  addition,  cough  and  expectoration  occur,  involvement  of  the 
lungs  is  possible.  The  character  of  the  expectoration  points  conclu- 
sively to  the  nature  of  the  lung  complication.  After  a  period  of  dry, 
hacking  cough,  sudden  expectoration  of  muco-purulent  or  bloody  spu- 
tum takes  place.  It  is  of  a  dirty-red  or  brownish  color,  not  unlike 
anchovy  sauce.  From  this  time  on  this  material  is  expectorated  in  vary- 
ing quantities  after  a  paroxysm  of  coughing.  The  expectoration  is 
diffluent,  tenacious,  and  frothy.  It  varies  in  color  from  bright  red  to 
russet-brown;  it  may  be  bile-stained.  The  sputa  are  alkaline;  the 
odor  is  not  putrid.  At  a  later  period  they  become  more  purulent, 
and  contain  less  blood.  The  sputum  separates  into  three  layers  :  an 
upper  frothy  layer,  a  middle  layer  of  turbid  fluid,  a  thin  layer  of 
muco-pus  below.  Large  amounts  may  be  coughed  up  in  twenty-four 
hours  ;  the  sputa  contain,  on  examination,  blood-corpuscles,  leucocytes, 
round  alveolar  epithelial  cells  and  polyhedral,  fatty  degenerated  cells 
which  look  like  liver-cells.  Elastic- tissue  fibres  from  the  lungs  are 
found  with  crystals  of  hseinatoidin  and  ty rosin,  and  Charcot's  crystals. 
Bacteria  are  present.  Amoebae  are  constantly  present.  They  vary  in 
size  and  activity,  but  are  larger  than  those  seen  in  the  stools.  The 
sputum  should  be  kept  warm  and  examined  as  soon  as  possible. 

Peritonitis.  Peritonitis  from  perforation  is  not  a  common  compli- 
cation of  amoebic  dysentery,  but  takes  place  occasionally  in  the  gan- 
grenous form.  Peritonitis  without  perforation  may  occur.  The 
symptoms  do  not  differ  from  peritonitis  under  other  circumstances. 
Hemorrhage  from  the  bowel  occurs  and  may  be  sufficiently  profuse  to 
cause  death.  Other  complications  which  have  been  described  under 
catarrhal  and  croupous  dysentery  are  likely  to  occur  in  this  affection. 

The  Diagnosis.  The  diagnosis  of  this  form  of  dysentery  is  made 
absolute  by  finding  the  amoebae  in  the  stools.  The  history  and  the 
course  of  the  illness  must  also  be  taken  into  consideration,  the  charac- 
teristics of  which  have  .been  previously  detailed.  The  irregularity, 
and  the  intermittency  of  the  diarrhoea,  the  infrequeney  of  tenesmus, 


592  SPECIAL  DIAGNOSIS. 

the  moderate  fever,  the  reaction  of  the  stools,  and  their  comparative 
freedom  from  bacteria,  are  further  corroborative  points. 

Cholera  Morbus.  The  attack  is  characterized  by  sudden  vomit- 
ing, followed  in  a  short  time  by  purging.  The  vomiting  may  be  pre- 
ceded by  pain,  or  both  may  occur  at  the  same  time.  At  first  the  pain 
is  seated  in  the  epigastrium  and  subsequently  about  the  navel.  It  is 
very  severe  and  paroxysmal  in  character,  compelling  the  patient  to 
double  up  if  lying  in  bed.  A  cold  perspiration  breaks  out  on  the 
forehead,  the  extremities  become  cold,  the  face  is  anxious,  the  pulse 
becomes  rapid.  At  first  the  patient  vomits  undigested  food,  then 
watery,  greenish-colored  fluid.  The  latter  is  bitter.  Purging  sets  in 
at  once,  or  within  an  hour.  The  bowel-movements  follow  an  attack 
of  pain.  The  first  passage  is  fsecal,  and  may  contain  undigested  food, 
the  subsequent  passages  are  watery  and  profuse.  There  are  severe 
attacks  of  burning  aud  tenesmus  ;  the  abdomen  is  tender  around  the 
navel  and  in  the  epigastrium.  After  an  evacuation  there  is  slight 
relief,  but  soon  another  paroxysm  of  pain  comes  on.  The  vomiting 
is  excessive,  and  retching  may  be  present  in  the  intervals.  Ice,  or 
water,  or  anything  taken  into  the  stomach  excites  pain  and  causes  the 
vomiting.  The  attack  subsides  in  twelve  to  twenty-four  hours,  and  is 
followed  by  exhaustion.  In  rare  cases  collap-e  ensues,  and  in  others 
it  is  followed  by  gastro-intestinal  catarrh. 

Cholera  Nostras.  The  symptoms  are  those  of  severe  gastro- 
enteritis. There  are  sudden  vomiting  and  diarrhoea.  It  usually  begins 
in  the  night.  The  vomiting  is  not  different  from  that  of  cholera 
morbus.  The  watery  and  brownish-colored  stools  become  colorless 
and  have  the  appearance  of  rice-water.  Pain  attends  the  attack,  rapid 
prostration  ensues,  the  extremities  become  cold,  and  collapse  takes 
place.  With  the  collapse  there  are  cramps  in  the  legs.  Other  mus- 
cles of  the  body  may  become  cramped.  The  disease  occurs  in  epidemics 
during  the  hot  season,  and  may  be  mistaken  for  cholera.  It  can  be 
distinguished  only  by  the  absence  of  the  comma-bacillus  from  the  milder 
forms  of  cholera  which  precede  the  occurrence  of  the  epidemic.  The 
bacillus  of  cholera  nostras  is  found  in  the  stools  (see  Fseces). 

Chronic  Intestinal  Catarrh.  It  usually  follows  an  acute  attack, 
or  may  be  chronic  from  the  start.  It  arises  secondarily  to  portal  con- 
gestion in  disease  of  the  liver  or  spleen,  to  chronic  disease  of  the  heart 
or  of  the  lungs.     It  occurs  in  malaria  and  in  the  scorbutic  cachexia. 

The  symptom  is  diarrhoea  alternating  with  constipation,  or  diarrhoea 
alone.  Stools  may  contain  undigested  food,  or  pus  and  mucus  and 
blood  in  small  amounts.  Diarrhoea  may  be  present  in  the  morniug 
only,  under  these  circumstances.  If  the  faeces  are  examined,  the  eggs 
of  parasites,  or  infusoria  may  be  found.  The  local  abdominal  symp- 
toms of  rumbling,  flatulency,  and  tormina  are  present.  There  are 
reflex  symptoms  of  cardiac  palpitation  and  dyspnoea  (asthma).  Rush 
of  blood  to  the  head  may  occur.  Often  these  symptoms  are  relieved 
by  the  passage  of  flatus.  Chronic  catarrhal  gastritis  usually  accom- 
panies the  intestinal  catarrh.  The  general  symptoms  of  anosmia,  ema- 
ciation, and  neurasthenia  are  present.     Hemorrhoids  are  common. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     593 

Ulceration  of  the  Intestines. 

Duodenal  Ulcer.  Ulcer  of  the  duodenum  usually  occurs  in 
young  subjects  in  whom  there  are  symptoms  of  chlorosis  or  anaemia. 
The  causes  are  the  same  as  those  of  gastric  ulcer.  It  may  follow  boils, 
erysipelas,  or  pemphigus,  and  differs  in  one  etiological  respect  from 
ulcer  of  the  stomach  in  that  it  occurs  most  frequently  in  the  male  sex. 
The  symptoms  are  obscure,  and  may  be  wanting  entirely,  the  patient 
probably  complaining  only  of  intestinal  indigestion.  In  other  cases 
they  are  like  those  of  gastric  ulcer.  In  typical  cases  the  symptoms  are 
those  of  pain  situated  below  the  xiphoid  or  to  the  right  of  the  median 
line  in  the  region  of  the  pylorus.  The  pain  occurs  after  eating,  and 
may  be  relieved  by  vomiting.  There  is  localized  tenderness  on  pres- 
sure. Hemorrhage  may  take  place  from  the  stomach,  or  blood  be 
found  in  the  stools  alone.  It  differs  from  gastric  ulcer  only  in  the 
possible  difference  in  location  of  the  pain,  the  occurrence  of  intestinal 
indigestion  and  gastric  hemorrhage,  and  the  fact  that  the  pain  continues 
several  hours  after  eating. 

General  Ulceration.  Ulceration  of  the  intestine  may  be  due  to 
a  specific  infection,  and  hence  be  symptomatic  of  typhoid  fever,  syph- 
ilis, and  tuberculosis.  It  is  always  present  in  the  first  mentioned,  and 
of  frequent  occurrence  in  the  latter.  Follicular  ulceration  occurs  in 
entero  colitis  in  children.  Ulcers  due  to  the  pressure  of  faeces  occur  in 
typhlitis  and  chronic  constipation.  The  sacculi  of  the  colon  become 
filled  with  scybalous  masses,  the  pressure  of  which  produces  ulcers. 
Tenderness  is  experienced  along  the  course  of  the  colon,  particularly 
on  palpation  of  the  faecal  masses,  which  may  be  felt  through  the 
abdominal  wall.  A  non-specific  chronic  ulcerative  colitis  is  the  form 
that  succeeds  the  diarrhoeas  which  occur  during  camp-life,  or  that  are 
set  up  in  communities  where  people  are  crowded  and  live  under  bad 
hygienic  circumstances.  It  is  the  form  that  attends  scurvy,  and  is 
frequently  seen  in  chronic  Bright' s  disease.  It  may  be  succeeded  by 
dilatation  of  the  colon,  by  hypertrophy  of  the  muscular  walls,  or  by 
contraction  of  the  bowel.  The  persistent  diarrhoea  leads  to  profound 
emaciation,  extreme  prostration,  sallow  complexion,  with  markedly 
impaired  nutrition  of  the  skin.  Such  forms  of  diarrhoea  were  seen 
during  the  late  war,  particularly  in  soldiers  held  in  captivity.  The 
diarrhoea  may  first  be  of  a  lienteric  character,  and  later  alternate  with 
constipation.  Stools  contain  blood  and  mucus.  Most  of  the  pensions 
given  to  soldiers  at  the  present  time  are  granted  because  of  this  disease. 

Ulcers  of  the  intestinal  tract  may  occur  from  other  causes,  and  diar- 
rhoea may  be  the  predominant  symptom.  They  may  be  due  to  cancer ; 
the  malignant  nodules  may  ulcerate  within  the  lumen  of  the  bowel. 
The  bowel  may  be  perforated  from  the  exterior,  on  account  of  suppu- 
ration somewhere  along  its  course,  as  in  appendicitis,  pancreatitis,  or 
tuberculous  peritonitis.  The  .symptoms  of  intestinal  ulcer  are  usually 
those  of  diarrhoea.  Ulceration,  however,  may  be  present  without  any 
symptoms  whatsoever,  particularly  if  the  small  intestine  is  affected. 
One  or  two  small  ulcers,  on  the  other  hand,  in  the  lower  portion  of 
the  colon  may  set  up  continuous  diarrhoea.     The  stools  are  composed  of 

38 


594  SPECIAL  DIAGNOSIS. 

faeces,  mucus,  pus,  shreds  of  tissue,  and  blood.  If  pus  is  discharged 
in  large  amounts,  an  abscess  has  probably  opened  into  the  bowel.  Mod- 
erate discharge  of  pus  usually  follows  ulcers  in  the  colon.  Pus  may 
be  present  in  cancer.  Hemorrhage  is  of  frequent  occurrence,  and  is 
an  important  diagnostic  symptom,  especially  if  profuse  and  occurring 
without  symptoms  of  obstruction,  of  gastric  ulcer,  or  of  hemorrhoids. 
The  fragments  of  tissue  found  in  the  stools  may  point  to  the  nature  of 
the  process.  Large  amounts  attend  the  dysenteric  process.  The  frag- 
ments may  be  composed  of  the  mucosa,  connective  tissue,  and  the 
muscular  coat.  Pain  occurs  in  mauy  of  the  cases.  It  may  be  general 
and  colicky,  or  circumscribed  in  cases  of  ulcer  of  the  colon.  Perfor- 
ation of  the  intestine  is  followed  by  localized  or  general  peritonitis. 
The  occurrence  of  the  latter  depends  largely  upon  the  situation  and  the 
rapidity  of  the  ulceration.  If  the  perforation  is  in  the  posterior  wall 
of  the  colon,  a  circumscribed  abscess  may  develop.  When  it  is  situ- 
ated in  the  upper  zone  the  pus  may  accumulate  underneath  the  dia- 
phragm, or  in  the  lesser  peritoneal  cavity.  The  signs  of  pyopneumo- 
thorax subphrenicus  occur  when  the  latter  accident  takes  place,  as  both 
pus  and  air  accumulate  in  the  abscess-cavity.  In  such  instances  the 
ulceration  usually  takes  place  at  the  splenic  flexure.  Perforation  of 
an  ulcer  of  the  caecum  may  simulate  appendicitis. 

Intestinal  Obstruction. 

Intestinal  obstruction  may  be  acute  or  chronic,  depending  upon  the 
cause  of  the  disease.  Acute  intestinal  obstruction  is  due,  first,  to  con- 
striction by  bands  or  strangulation  of  the  bowel  through  apertures  ; 
second,  to  volvulus  of  the  colon  ;  third,  to  acute  intussusception.  In 
the  first  instance  the  type  of  the  obstruction  is  seen  in  strangulated 
hernia,  but  similar  strangulations  occur  in  apertures  within  the  perito- 
neal cavity.  Thus,  loops  of  the  intestine  are  caught  and  constricted 
in  the  duodeno-jejunal  fossa,  the  so-called  Trites'  retro-peritoneal  her- 
nia, or  in  the  foramiua  of  Winslow,  also  known  as  inter-sigmoid 
hernia  ;  finally,  diaphragmatic  hernia,  in  which  protrusions  of  the 
intestine  into  the  diaphragm  along  with  other  abdominal  viscera  may 
take  place.  The  above-mentioned  forms  of  hernia  may  exist  without 
symptoms,  or  may,  from  some  unknown  cause,  lead  to  constriction  or 
twisting  of  the  loop  of  the  intestine,  with  occurrence  of  acute  obstruc- 
tion. Moreover,  lacerations  in  the  omentum  may  give  rise  to  internal 
constrictions.  External  constrictions,  however,  take  place,  most  com- 
monly in  the  regions  of  hernias,  on  account  of  the  gut  being  constricted 
by  dense  fibrous  adhesion  ;  or  about  the  uterus  or  Fallopian  tubes, 
which  had  previously  been  the  seat  of  inflammation.  The  constrict- 
ing bands  that  follow  the  local  peritonitis  may  gradually  occlude  the 
gut,  or  be  in  such  position  that  the  latter  becomes  twisted  about  it. 
In  other  forms  of  peritonitis  similar  constricting  bands  may  form, 
which  are  liable  to  produce  this  accident.  Disease  about  the  vermi- 
form appendix,  with  secondary  adhesions,  has  been  observed  to  cause 
constriction.  A  frequent  form  of  intestinal  obstruction  is  due  to  the 
tangling  of  the  intestines  in  the  foetal  remains  of  the  omphalo-mesen- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     595 

teric  duct,  which,  as  well  as  Meckel's  diverticulum,  is  situated  a  short 
distance  above  the  ileo-ceecal  valve. 

Volvulus  is  a  form  of  obstruction  due  to  twisting  or  knotting  of  the 
intestine.  The  condition  is  not  common.  It  occurs  most  frequently 
at  the  sigmoid  flexure  of  the  colon.  The  mesentery  of  the  latter  is 
often  congenitally  narrowed,  on  account  of  which  the  colon  is  unduly 
drawo-ed  upon,  and,  if  filled  with  masses  of  faeces,  cannot  restore  itself; 
the  twisting  becomes  permanent,  and  obstruction  takes  place.  Jreri- 
stalsis  is  set  up  and  other  portions  of  the  intestine  wind  about  the 
pedicle  of  the  loops  so  as  to  form  a  regular  knot.  Abnormal  peris- 
talsis on  account  of  diarrhoea  often  precedes  the  appearance  of  the 
obstruction.  External  injury  is  said  also  to  give  rise  to  the  formation 
of  an  obstruction. 

Intussusception,  as  a  cause  of  intestinal  obstruction,  occurs  most 
frequently  in  children,  and  is  due  to  a  portion  of  the  bowel  being 
pushed  into  the  lumen  of  that  which  lies  next  below  it.  A  circum- 
scribed portion  of  the  intestine  may  be  paralyzed.  In  the  portion 
above,  the  peristaltic  action  continues  and  the  energetic  movements 
push  it  into  the  paralyzed  part.  Intussusception  is  found  frequently 
after  death  in  the  bodies  of  children  dying  from  exhaustion.  In  such 
cases  it  occurs  just  before  death.  Intussusception  also  occurs  when 
intestinal  polypi  drag  one  portion  of  the  bowel  into  the  lower  portion. 
Large  portions  of  the  intestine  may  be  involved.  The  invagination  usu- 
ally takes  place  at  the  lower  portion  of  the  ileum,  or  in  the  caecum ; 
sometimes  the  invaginated  portion  may  reach  the  rectum  and  project 
externally.  Intense  inflammation  and  adhesion  are  set  up.  The 
internal  portion  becomes  gangrenous  on  account  of  constriction  of  the 
afferent  vessels.  This  portion  may  slough  and  pass  with  the  dejections, 
followed  by  spontaneous  cure. 

Intestinal  obstruction,  to  view  it  from  another  standpoint,  may  be 
due  to  (a)  diseases  outside  of  the  intestines  ;  (b)  to  disease  in  the 
intestinal  walls  ;  (c)  to  accumulation  within  the  intestine. 

The  obstruction  takes  place  under  the  same  circumstances  as  obstruc- 
tion in  other  channels. 

A.  Diseases  Outside  of  the  Intestines.  1.  Pressure  of  tumors,  chiefly 
ovarian  tumors,  uterine  tumors,  tumors  of  the  omentum,  and  pelvic 
abscess,  or  abscess  about  the  caecum.  The  symptoms  of  obstruction 
develop  gradually,  although  in  some  instances  they  may  take  place 
suddenly,  especially  if  aided  by  the  accidental  occurrence  of  faecal 
impaction. 

2.  Constricting  bands,  hernial  openings,  the  remains  of  foetal  struc- 
tures, cause  constriction  of  the  intestine.  In  this  class  of  cases  there 
is  usually  pain,  and  the  history  preceding  the  obstruction  is  that  of 
peritonitis,  general  or  local,  of  old  hernia,  of  appendicitis,  of  pyosal- 
pinx,  or  of  inflammation  about  the  gull-bladder  and  gall-ducts.  If 
the  constriction  is  due  to  protrusion  into  hernial  openings,  the  onset 
is  usually  sudden  and  without  previous  symptoms. 

3.  Peritonitis  is  the  most  common  cause  of  intestinal  obstruction.  It 
may  be  due  to  ovcrdistontion  by  gas  and  paresis  of  the  bowel,  or  to 
pressure  by  external  exudation. 


596  SPECIAL  DIAGNOSIS. 

4.  Knots  aud  twists  of  the  intestines,  usually  seated  about  the  sig- 
moid flexure,  causing  volvulus,  are  a  common  cause  of  constriction. 

B.  Disease  of  the  Intestinal  Walls.  1.  Invagination,  or  intussuscep- 
tion, in  which  one  portion  of  the  bowel  is  drawn  into  the  other.  It 
usually  occurs  in  children  and  is  seated  in  the  right  lower  quadrant  in 
the  neighborhood  of  the  caecum.  The  attack  is  acute,  although  the 
atfection  may  continue  over  a  long  period  of  time. 

2.  Cancer  of  the  intestine  in  its  course  generally  leads  to  stricture 
and  obstruction. 

3.  The  healing  of  ulcers,  which  are  syphilitic  in  the  larger  number 
of  cases,  rarely  tuberculous,  will  lead  to  stricture.  The  obstruction 
takes  place  gradually  in  this  class  of  cases.  It  is  seated,  in  the  larger 
number  of  instances,  in  the  rectum  or  sigmoid  flexure  of  the  colon. 

C.  Accumulations  within  the  Intestines.  1.  Faeces.  The  obstruc- 
tion takes  place  gradually,  occurs  in  weak  and  debilitated  people  in  the 
course  of  constipation,  and  follows  the  constipation  of  acute  disease. 

2.  Accumulations  of  improper  food  or  foreign  materials.  The  seeds 
of  fruits  or  the  husks  of  grain  accumulate  and  cause  obstruction. 
Magnesia,  iron,  and  other  articles  taken  as  medicines,  from  their  accu- 
mulation lead  to  obstruction  of  the  intestine.  In  these  instances  the 
obstruction  takes  place  gradually. 

3.  Impaction  of  gallstone  within  the  intestine  is  followed  by  acute 
obstruction. 

It  will  be  observed  in  the  detailed  list  of  causes  that  obstruction  may 
be  acute  or  chronic.  Complete  acute  obstruction  may  set  in  in  the  course 
of  chronic  obstruction  due  to  stricture  of  the  bowel,  and  occlusion  due 
to  external  pressure  or  to  accumulations  within  the  bowel. 

In  a  case  in  which  the  symptoms  of  intestinal  obstruction  occur  it  is 
important  to  ascertain,  first,  the  duration  of  the  obstruction  and  mode 
of  onset;  second,  the  possible  cause  of  the  obstruction;  third,  the  seat 
of  the  obstruction.  The  symptoms  of  intestinal  obstruction  depend 
upon  the  nature  of  the  obstruction  and  the  rapidity  with  which  it  has 
taken  place.  Constipation.  In  all  forms  of  obstruction  the  one  symp- 
tom is  stoppage  of  the  intestinal  contents.  When  this  takes  place  sud- 
denlv,  and  at  the  same  time  there  is  a  local  injury  to  the  bowel,  the 
svmptoms,  both  local  and  general,  are  most  pronounced  and  alarming. 
On  account  of  the  obstruction  there  is  acute  constipation,  without  the 
escape  of  flatus.  Pain.  For  the  same  reason  there  is  pain  at  the  seat 
of  obstruction.  This  occurs  suddenly,  and  is  intense  and  lancinating 
in  character,  radiating  from  the  point  of  obstruction.  Over  the  part 
that  is  painful  there  is  tenderness.  Tumor.  In  many  instances  a 
tumor  can  be  outlined  due  to  single  loops  of  intestine,  thickened  walls, 
or  abnormal  contents.  This  is  particularly  the  case  in  the  obstruction 
of  invagination  and  the  obstruction  due  to  volvulus.  Pei^istalsis.  The 
obstruction  further  causes  increased  peristalsis.  This  takes  place  above 
the  point  of  constriction.  Sometimes  the  movements  of  the  intestine 
can  be  seen  through  the  abdominal  walls.  Meteorism.  The  obstruc- 
tion causes  accumulation  of  gas  above  the  point,  giving  rise  to  meteor- 
ism. If  the  obstruction  is  low  down,  the  distention  and  meteorismus 
are  general.      If  high  up,  as  in  the  small  intestine,  on  account  of  con- 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     597 

striction  by  Meckel's  diverticulum  or  internal  hernia,  the  meteorisin  is 
in  the  upper  part  of  the  abdomen,  and  may  be  limited  in  extent,  or 
dilatation  of  the  stomach  alone  may  be  present.  Vomiting.  Vomit- 
ing soon  occurs  in  acute  intestinal  obstruction  due  to  decomposition  of 
intestinal  contents,  to  irritation  of  the  stomach  by  the  intestinal  con- 
tents, to  a  trauma  of  the  peritoneum  at  the  seat  of  the  obstruction,  or, 
finally,  to  the  occurrence  of  peritonitis.  At  first  the  contents  of  the 
stomach  are  ejected,  then  watery  fluid,  bile-tinged  or  largely  made  up 
of  bile,  and  later  faeciilent  matter.  Although  of  faecal  odor,  true  ster- 
coraceous  vomiting  occurs  later  in  the  course  of  acute  intestinal  obstruc- 
tion. It  must  not  be  forgotten  that  any  obstruction  of  the  intestine 
may  develop  with  extreme  rapidity,  so  that  fsecal  vomiting  may  occur 
within  two  hours  of  the  commencement  of  an  obstruction.  It  is  recog- 
nized by  the  odor  of  the  matter  vomited  and  by  its  color.  It  is  a  grave 
symptom,  indicating  complete  obstruction  of  the  intestine.  Eructations 
of  gas  are  frequent.  The  general  symptoms  are  those  of  shock  in  its 
most  pronounced  form.  The  abdominal  fades  previously  described 
develops  very  rapidly.  In  a  few  instances,  as  in  invagination,  there 
may  be  fever,  yet  at  once,  or  very  soon  in  its  course,  the  temperature 
falls  to  normal  or  subnormal,  or  remains  at  this  point  if  it  has  not 
risen.  The  extremities  are  cold,  the  features  pinched,  the  eyes  sun- 
ken, the  expression  anxious.  The  pain  causes  the  patient  to  double 
up  in  bed.  The  pulse  becomes  rapid,  weak,  thready  in  character,  res- 
pirations proportionately  hurried.  The  mind  remains  clear  until  the 
supervention  of  peritonitis  and  septicaemia. 

Chronic  Obstruction.  The  symptoms  are  those  of  chronic  constipa- 
tion, with  local  symptoms  due  to  the  cause  of  the  obstruction.  The 
bowels  are  moved  infrequently,  and  then  in  small  amounts.  In 
obstruction  due  to  stricture  from  cancer,  or  cicatricial  closure,  the 
faeces  are  ribbon-shaped.  Reference  must  again  be  made  to  the  occur- 
rence of  diarrhoea,  with  or  without  the  passage  of  small  scybalous 
masses,  on  account  of  impaction  of  faeces.  Some  credence  can  be 
given  to  the  oft-repeated  expression  of  the  patients  that  they  have  a 
sense  of  obstruction  in  the  bowel  and  that  they  experience  great 
relief  when  there  is  a  free  evacuation.  In  chronic  obstruction  the 
general  symptoms  are  those  of  inanition,  with  the  nervous  train  of 
symptoms  that  have  been  described  in  constipation;  while  the  local 
symptoms  depend  upon  the  cause.  When  the  local  symptoms  are  due 
to  pressure  of  a  tumor,  or  accumulation  of  pus  or  fluid  within  the 
abdomen,  there  is  a  history  of  local  disease,  on  account  of  which  the 
tumor  developed  ;  such  history  is  obtained  in  fibroids  or  ovarian 
tumor,  or  in  previous  inflammation,  which  was  followed  by  the  occur- 
rence of  a  tumor  about  the  locality  of  the  inflammation,  as  the  pelvis 
or  the  appendix. 

If  the  obstruction  is  due  to  cancer  of  the  intestine,  the  symptoms  of 
that  affection  are  present.  A  tumor  can  be  made  out  at  some  situation 
in  the  course  of  the  bowel.  The  symptoms  are  (1)  the  cachexia, 
emaciation,  and  anaemia;  (2)  pain;  (;})•  tumor;  (4)  constipation  with 
scybalous  discharge;  (5)  bloody  discharge;  (6)  mucous  discharge. 
If  the  cancer  is  seated  in  the  rectum,  we  find  tormina  and  tenesmus, 


598  SPECIAL  DIAGNOSIS. 

and  the  discharge  of  blood  and  scybalous  masses.  Local  examination 
reveals  the  presence  of  a  malignant  mass.  Obstruction  due  to  stricture 
from  the  healing  of  an  ulcer  is  seated  in  the  rectum  or  sigmoid  flexure 
of  the  colon.  Pain  and  a  sense  of  obstruction  are  referred  to  that 
locality.  A  history  of  syphilis  can  be  obtained,  and  frequently  the 
rectal  tube,  or  the  finger,  Avill  detect  the  stricture.  In  both  instances 
there  is  a  history  of  imperfect,  irregular  action  of  the  bowels  from 
time  to  time,  with  intervals  of  comparative  comfort.  These  symp- 
toms precede  the  constipation.  When  faeces  accumulate  in  the  colon 
the  larger  accumulations  take  place  in  the  sigmoid  flexure  and  in  the 
caecum.  Faecal  tumors,  described  under  Constipation,  are  felt  through 
the  abdominal  walls.  Obstruction  from  faecal  accumulation  is  pre- 
ceded by  a  history  of  constipation  (q.  v.).  The  accumulations  can  be 
easily  discerned  as  a  rule.  It  must  not  be  forgotten  that  chronic  intes- 
tinal obstruction  may  at  any  time  become  acute. 

Chronic  intestinal  obstruction  always  occurs  in  adults.  The  onset 
is  gradual.  The  pain  that  attends  obstruction  of  this  form  is  inter- 
mittent, and  if  there  is  faecal  accumulation,  it  is  not  very  prominent. 
Vomiting  occurs  late  in  the  disease,  is  small  in  amount,  and  gener- 
ally is  not  a  prominent  factor.  Obstruction  to  the  passage  of  faeces 
may  be  constant,  or  alternate  with  diarrhoea.  In  faecal  accumula- 
tion it  becomes  complete,  although  spurious  diarrhoea  may  attend  it. 
The  discharges  may  be  bloody,  which  points  to  cancer.  Tenesmus  is 
present  in  stricture  low  down  in  the  large  bowel.  Meteorism  is  not 
marked  when  obstruction  is  high  up,  as  in  acute  obstruction.  When 
the  obstruction  is  in  the  large  intestine  it  may  be  extreme,  and  in 
faecal  obstruction  gradually  increases  as  the  obstruction  becomes  more 
marked. 

The  forms  of  chronic  obstruction  that  are  attended  by  tumor  have 
been  mentioned.  Coils  of  intestine  in  peristaltic  movement  are  seen 
only  in  cases  in  which  there  is  marked  emaciation. 

Differential  Diagnosis.  When  the  symptoms  of  acute  obstruction 
are  present  it  is  essential  to  distinguish  the  form  by  ascertaining  the 
nature  of  the  obstruction,  and  determining,  if  possible,  its  seat.  Vari- 
ous factors  must  be  considered  in  order  to  estimate  the  cause  of  the 
obstruction. 

The  Age.  Obstruction  from  intussusception  occurs  early  in  life; 
from  bands  or  through  apertures,  in  adult  life,  usually  prior  to  forty 
years  of  age;  in  volvulus,  between  forty  and  sixty  years.  Obstruc- 
tion due  to  a  gallstone  occurs  during  the  middle  or  later  period  of 
life — always  after  the  fortieth  year. 

Previous  History.  In  obstruction  by  bands  of  adhesion  there  is  a 
history  of  peritonitis,  or,  as  Treves  points  out,  previous  attacks  of 
obstruction  more  or  less  marked.  In  volvulus  the  patient  has  been 
subject  to  constipation  prior  to  the  attack,  and  in  intussusception  there 
has  been  no  previous  history,  unless  polypus  was  present,  causing 
dragging,  colicky  pains,  and  occasional  discharge  of  blood. 

Symptoms.  The  symptoms  of  the  various  forms  of  acute  obstruction 
vary  somewhat.  Pain  in  strangulation,  from  bands  or  hernia,  is  severe 
and  paroxysmal  in  character,  attended  by  collapse.     It  occurs  early  in 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     599 

volvulus,  though  it  is  not  so  severe  as  in  the  former,  and  occurs  a^ 
long-  intervals,  becoming  constant  with  exacerbations.  In  acute  intus- 
susception the  pain  occurs  early,  and  is  steady.  It  increases,  and  then 
may  suddenly  subside.  At  first  it  is  paroxysmal,  attending  discharge 
of  blood  and  mucus  from  the  bowels.  Local  tenderness  in  the  first 
group  of  cases  occurs  late.  In  volvulus  it  occurs  early,  and  may  be 
noted  over  distended  coils.  In  intussusception  it  is  usually  common 
about  a  sausage-shaped  tumor.  Vomiting  is  marked  and  occurs  in 
strangulation,  soon  becomes  fseculent,  and  increases  the  severity  of  the 
paroxysms  of  pain.  In  volvulus  it  does  not  come  on  so  quickly)  but 
is  severe  and  constant  when  it  takes  place.  The  relaxation  that  attends 
vomiting  often  affords  relief  to  the  obstruction.  In  intussusception  it 
does  not  occur  as  early  as  in  the  other  forms,  and  is  not  so  severe.  It 
becomes  fseculent  in  only  a  small  number  of  cases. 

Constipation  is  continuous  in  all  cases  except  intussusception.  In 
the  latter  there  is  some  constipation,  but  it  is  not  absolute ;  diarrhoea 
is  not  uncommon,  and  discharge  of  blood  in  the  stools  occurs  in  80  per 
cent,  of  the  cases,  according  to  Treves.  Prostration  is  severe  in  all 
cases,  although  probably  not  so  marked  in  volvulus.  Because  of  its 
close  proximity  to  the  rectum  tenesmus  occurs  in  volvulus  and  is  of 
frequent  occurrence  in  intussusception,  often  beginning  early  in  the 
attack. 

Physical  Signs.  On  palpation  of  the  abdominal  wall  it  is  noted  to 
be  soft  and  flaccid  in  most  of  the  cases,  unless  peritonitis  has  ensued. 
This  occurs  early  in  volvulus,  and  rigidity  is  likewise  marked.  In  a 
large  number  of  cases  a  tumor  can  be  made  out  only  in  intussusception. 
It  is  seated  in  the  lower  right  quadrant  of  the  abdomen.  Early  in  the 
attack  it  is  oblong  and  of  sausage-shape.  When  peritonitis  ensues  it 
disappears  on  account  of  the  tympany.  A  portion  of  the  gut  may 
protrude  at  the  anus,  or  be  felt  on  rectal  examination.  Meteorism 
occurs  about  the  third  day  in  a  strangulation  ;  it  occurs  early,  is  very 
rapid  and  pronounced  in  volvulus,  and  is  absent  in  intussusception, 
unless  constipation  takes  place. 

The  Seat  of  Obstruction.  The  seat  of  obstruction  is  in  a  measure 
indicated  by  (1)  the  location  of  the  pain  or  abnormal  sensations,  (2)  the 
character  of  the  swelling,  (3)  the  character  of  the  stools,  (4)  the  degree 
of  meteorism,  and  (5)  the  results  of  a  rectal  examination.  The  patient 
is  often  able  to  indicate  the  location  of  the  obstruction  fairly  well  by 
the  sensations  of  obstruction  or  fulness  and  by  the  great  relief  experi- 
enced when  a  free  evacuation  of  the  bowels  is  naturally  or  artifieally 
produced.  On  auscultation,  when  the  bowel  is  irrigated,  a  murmur, 
like  the  deglutition-murmur,  may  be  heard  at  the  point  of  constriction  of 
the  gut.  In  obstruction  high  up  there  is  but  little  meteorism,  the  tumors 
are  usually  not  detected,  and  pain  is  seated  about  the  umbilicus  or  the 
upper  quadrants  of  the  abdomen.  Obstruction  at  the  ileo-csecal  valve 
may  be  indicated  by  a  tumor  in  the  lower  right  quadrant  over  the  region 
of  the  valve  or  just  above  it.  It  is  usually  at  this  point  that  invagina- 
tion takes  place,  and  hence  we  may  look  for  tumor  in  this  situation. 
On  the  other  hand,  in  volvulus  of  the  colon,  or  stricture  of  the  rectum, 
the  obstruction  being  low  down,  is  attended  by  much  meteorism  and 


600  SPECIAL  DIAGNOSIS. 

pain  in  the  left  lower  quadrant  of  the  abdomen.  In  volvulus  a  tumor 
may  be  detected  in  this  position,  and  there  is  much  meteorism.  The 
position  of  the  obstruction  is  sometimes  indicated  by  the  seat  of  peri- 
stalsis. This  may  be  seen  to  stop  at  a  given  point,  which  usually  indi- 
cates the  position  of  the  obstruction.  The  seat  of  obstruction  may  be 
indicated  by  the  number  of  coils  of  intestine  that  are  engaged  in  the 
peristaltic  movement.  The  coils  of  intestine  in  front  of  the  tumor  are 
dilated  and  hypertrophied.  In  active  movement  they  cause  promi- 
nences which  follow  the  course  of  the  bowel.  Wyllie  has  called  them 
"patterns  of  abdominal  tumidity."  If  the  lower  end  of  the  large 
intestine  is  obstructed,  the  colon  is  prominent;  if  the  gut  about  the 
ileo-csecal  valve,  the  region  about  and  below  the  umbilicus  is  prominent. 
Obstruction  in  the  duodenum  or  jejunum  is  followed  by  collapse  and 
anuria  In  general,  it  may  be  said  the  more  severe  and  rapid  the 
symptoms  the  more  likelihood  that  the  obstruction  is  in  the  small 
intestine. 

The  Urine.  The  position  of  the  tumor,  it  is  said,  can  be  ascertained 
by  changes  in  the  urine.  When  the  obstruction  is  in  the  small  intes- 
tine indican  is  much  increased  from  the  decomposition  of  albuminous 
substances  and  other  products  of  putrefaction.  In  this  location  the 
urine  may  be  suppressed.  In  stenosis  of  the  large  intestine  it  is  uot 
increased  unless  there  is  cancer. 

Intussusception  or  invagination  occurs  most  frequently  in  children 
prior  to  the  tenth  year.  It  is  characterized  by  severe  colic  and  pain 
in  the  abdomen,  first  complained  of  about  the  navel.  The  severity 
increases  in  paroxysms,  and  only  lessens  if  complete  strangulation  has 
taken  place.  With  the  onset  of  the  pain  there  are  one  or  two  move- 
ments of  the  bowels  which  contain  mucus  and  blood.  After  this  there 
may  be  constipation,  or  the  stools  continue  to  be  loose,  and  are  as  fre- 
quent as  fifteen  or  twenty  in  a  day.  Sometimes  they  are  quite  bloody, 
and  almost  always  there  is  some  tenesmus.  In  a  short  time  after  the 
attack  vomiting  commences.  It  may  be  constant  or  occur  only  after 
taking  food.  At  first  the  abdomen  is  soft,  but  tender  on  pressure. 
A  sausage-like  tumor  may  be  felt  on  the  right  side  below  the  trans- 
verse umbilical  line.  On  inspection  of  the  rectum  a  portion  of  the 
intestine  may  be  seen,  dark  and  gangrenous  in  appearance,  or  it  may 
be  felt  by  palpation.  If  there  is  much  tenesmus,  the  anus  often  remains 
open.  In  rare  cases  the  bowel  may  slip  back  and  the  symptoms  sub- 
side spontaneously.  On  the  other  hand,  peritonitis  may  rapidly  ensue, 
with  high  fever,  followed  by  collapse  and  death. 

Diagnosis.  It  must  be  distinguished  from  the  enter  o- colitis  of  child- 
hood or  the  proctitis  due  to  a  polypus.  In  entero-colitis  there  is  no 
tumor,  and  the  collapse  and  prostration  do  not  occur  so  early  and  are 
not  so  rapid.  There  is  greater  likelihood  of  a  number  of  the  stools 
being  greenish,  like  spinach.  In  a  polypus  of  the  rectum  the  symp- 
toms are  local,  the  child  is  worn  out  and  restless,  but  great  abdominal 
tenderness,  and  the  tumor,  meteorism,  vomiting,  and  collapse  do  not 
take  place      The  rectum  must  be  examined. 

Intussusception  must  be  distinguished  from  peritonitis,  in  which 
symptoms  of  stenosis  of  the  bowel  from  ileus  paralytica  may  be  present. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     601 

The  history  and  sequence  of  events  must  be  watched  carefully.  Often 
the  commencement  of  the  affection  about  hollow  viscera  which  have 
previously  been  the  seat  of  disease,  or  its  onset  with  sudden  perfora- 
tion, will  point  to  the  nature  of  the  affection.  In  peritonitis  there  is 
no  active  peristalsis  ;  there  is  general  distention  of  the  abdomen, 
with  general  tenderness  ;  the  urine  is  diminished,  but  does  not  contain 
indican  in  excess.  Collapse  ensues  rapidly.  Signs  of  effusion  within 
the  abdomen  may  appear. 

It  must  be  distinguished  from  embolism  or  thrombosis  of  the  mesen- 
teric  artery  and  infarction  of  the  bowel. 

The  symptoms  take  place  suddenly.  The  patients  have  reached 
middle  or  late  life,  and  have  atheroma  of  the  general  arterial  system. 
Sudden  pain  in  the  abdomen,  with  vomiting  and  symptoms  of  collapse, 
takes  place.  Moderate  obstruction  occurs  with  distention  of  the  abdo- 
men. After  the  pain  diarrhoea  with  the  passage  of  blood  follows. 
The  age  and  the  absence  of  tumor  distinguish  it  from  intussusception, 
the  only  intestinal  condition  for  which  it  may  be  mistaken. 

Course  of  Hernia  and  Volvulus.  Obstruction  due  to  these  conditions 
occurs  in  adults  after  the  fortieth  year  of  age,  in  both  sexes.  In  stric- 
ture from  the  pressure  of  bands  there  has  usually  been  a  history  of 
previous  attacks  of  peritonitis  or  of  inflammation  of  the  structures  in 
relation  to  the  peritoneum.  The  attacks  begin  suddenly,  and  the  symp- 
toms may  from  the  start  be  most  pronounced.  They  are  the  typical 
symptoms  of  intestinal  obstruction  previously  described.  The  local 
tenderness,  however,  may  not  be  present  as  early  as  in  other  forms  of 
obstruction.  It  is  quite  characteristic  to  find  a  tumor  or  positive  local 
cause  for  the  obstruction,  also  not  to  have  meteorismus.  This  is  due  to 
the  fact  that  the  obstruction  is  usually  high  up  in  the  intestinal  tract. 

Volvulus.  Volvulus  occurs  most  frequently  in  males.  It  occurs 
late  in  life,  and  is  usually  preceded  by  a  history  of  constipation. 
Premonitory  symptoms  may  have  been  present  for  a  few  days,  but 
the  symptoms  of  obstruction  take  place  suddenly.  They  are  the  symp- 
toms of  acute  obstruction,  but  as  the  lesion  is  in  the  lower  portion  of 
the  bowel  meteorismus  is  present  to  a  marked  degree,  and  rectal  symp- 
toms are  found.  Tenesmus  is  present  in  a  small  proportion  of  the 
cases.  Peritonitis  is  likely  to  set  in  early  with  increase  in  the  temper- 
ature, increased  tenderness  of  the  abdomen,  and  more  pronounced 
symptoms  of  collapse. 

Diagnosis  of  Intestinal  Obstruction.  Intestinal  obstruction 
must  be  distinguished  from  peritonitis  and  appendicitis.  This  is  some- 
times very  difficult.  Careful  attention  must  be  paid  to  the  evolution 
of  the  case  and  the  history  of  previous  abdominal  disease,  or  of  lesions 
on  account  of  which,  on  the  one  hand,  peritonitis  may  occur,  or,  on  the 
other,  obstruction  of  the  bowel.  In  peritonitis  the  attack  follows  dis- 
ease in  the  uterine  appendages,  the  vermiform  appendix,  or  the  gall- 
bladder, or  perforation  in  some  portion  of  the  gastro-intostinal  tract. 
Fever  usually  attends  the  inflammation,  with  or  without  chill.  Vom- 
iting  will  probably  occur  at  the  onset,  and  then  subside  until  the  peri- 
tonitis becomes  general.  •  The  first  paroxysms  of  vomiting  are  apparently 
due  to  shock.    The  vomiting  that  occurs  rarely  becomes  fseculent.    As 


602  SPECIAL  DIAGNOSIS. 

the  peritonitis  advances  the  vomiting  becomes  passive  ;  a  simple  con- 
stant regurgitation  of  a  large  amount  of  fluid,  greenish  or  grayish- 
yellow,  or  watery,  takes  place.  It  pours  into  the  mouth,  and  is  simply 
discharged  without  the  occurrence  of  retching.  The  abdomen  is  swol- 
len and  tympanitic.  The  symptoms  due  to  excessive  tympany  are 
more  marked  than  in  intestinal  obstruction.  The  diaphragm  is  inter- 
fered with,  breathing  is  hurried.  The  abdomen  is  tender  on  pressure 
and  is  the  seat  of  general  pain.  The  general  pain  and  tenderness, 
however,  can  usually  be  found  to  be  more  marked  at  the  possible 
primary  focus  of  the  disease.  Further,  on  local  examination,  in  these 
positions  fulness  or  undue  prominence  or  swelling  may  be  observed. 
On  palpation  over  the  point  of  origin  there  may  be  localized  ozdema. 
The  symptoms  of  collapse  do  not  differ  from  those  of  intestinal  obstruc- 
tion in  marked  degree,  although  the  peculiar  appearance  of  the  face 
and  other  nervous  features  occur  more  rapidly  in  peritonitis  than  in 
obstruction.  It  must  be  remembered  that  peritonitis  in  a  large  majority 
of  cases  attends  obstruction. 

In  appendicitis  the  symptoms  are  somewhat  like  those  of  intestinal 
obstruction.  There  may  be  constipation  and  vomiting.  The  former 
is  not  pronounced,  and  can  usually  be  relieved.  Vomiting  subsides 
after  the  first  twenty -four  hours,  unless  peritonitis  supervenes;  it  is 
never  stercoraceous.  The  local  physical  signs  are  characteristic.  In 
appendicitis  there  is  fixed  tenderness  on  pressure  at  McBurney's  point. 
Some  swelling  can  almost  always  be  observed.  On  light  or  deep 
percussion  there  is  change  in  the  note  as  compared  with  the  other  side. 
Fluctuation  cau  often  be  detected  in  from  two  to  four  or  five  days. 
Both  the  tumor  and  fluctuation  can  be  detected  by  bimanual  examination 
of  the  abdomen  and  flank.  Examination  by  the  rectum  may  reveal  a 
tumor  at  the  brim  of  the  pelvis  in  the  right  side.  Fever  attends  the  at- 
tack throughout.  When  peritonitis  supervenes  there  is  rigidity  of  the 
entire  abdomen,  which  at  first  was  localized  to  the  right  lower  quadrant. 

Intestinal  obstruction  must  not  be  confounded  with  enteritis.  In 
all  forms  there  is  diarrhoea,  in  many  vomiting.  Pain  of  a  colicky 
nature,  spreading  from  the  neighborhood  of  the  umbilicus,  is  marked 
whenever  obstruction  to  the  passage  of  faeces  or  gas  takes  place.  Vom- 
iting is  not  stercoraceous,  and  the  general  symptoms,  collapse,  etc.,  do 
not  occur.  Acute  hemorrhagic  pancreatitis  is  also  attended  by  symp- 
toms similar  to  those  of  intestinal  obstruction.  There  is  sudden  severe 
pain  in  the  upper  half  of  the  abdomen,  with  vomiting  and  the  rapid 
development  of  collapse ;  there  may  be  constipation  ;  the  situation  of 
the  pain  is  of  some  significance.  Vomiting  never  becomes  stercora- 
ceous; flatus  can  usually  be  passed  and  the  bowels  opened  by  an  enema. 
Meteorismus  does  not  take  place,  although  the  epigastrium  is  tym- 
panitic. If  the  symptoms  are  not  so  "severe,  there  may  be  increased 
dulness,  and  possibly  a  tumor  on  deep  palpation  in  the  left  upper 
quadrant  of  the  abdomen  along  the  margins  of  the  ribs,  which  should 
be  dull  on  percussion,  or,  on  account  of  its  relation  to  the  stomach, 
give  a  dull  tympanitic  note.  The  symptoms  of  internal  hemorrhage 
are  present,  pallor  of  the  face  and  extremities,  syncope,  and  in  addition 
prostration  and  other  symptoms  of  collapse. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     603 

Appendicitis. 

This  is  by  far  the  most  important  affection  of  the  intestinal  tract. 
It  is  of  frequent  occurrence  compared  with  intestinal  obstruction,  and, 
if  recognized,  is  amenable  to  relief  in  a  very  large  percentage  of  the 
cases;  whereas  intestinal  obstruction  is  more  frequently  fatal.  We  see 
twenty-five  cases,  at  least,  of  appendicitis  in  all  its  forms  to  one  case 
of  any  form  of  obstruction.  Its  importance,  therefore,  is  readily 
recognized.  Appendicitis  occurs  most  frequently  in  the  young — in  the 
large  proportion  of  cases  under  thirty.  1  have  seen  it  as  early  as  two 
years  of  age,  although  from  the  fifteenth  to  the  thirtieth  year  it  is  more 
frequent  than  at  any  other  period.  The  symptoms  vary,  but  clinically 
may  be  divided  into  those  of  appendicitis  without  perforation  and  appen- 
dicitis with  perforation.  Appendicitis  without  perforation  is  charac- 
terized by  relapses,  and  is  known  also  as  recurring  appendicitis. 

Appendicitis  without  Perforation.  There  are  probably  cases 
of  catarrhal  appendicitis,  although  I  am  not  prepared  to  say  that 
catarrhal  inflammation  of  the  appendix  gives  rise  to  marked  local 
symptoms,  for,  in  cases  on  the  post-mortem  table  in  which  the  lesions 
of  catarrh  were  found,  there  had  not  been  any  symptoms  during  life 
due  either  to  intestinal  catarrh  or  to  any  symptoms  pointing  to  appen- 
dicitis in  any  form.  Moreover,  many  cases  in  which  the  attacks  of 
appendicitis  had  at  first  been  slight,  finally  developed  into  appendicitis 
with  perforation.  In  the  milder  cases,  if  operative  measures  are 
resorted  to  during  the  intervals  between  the  attacks,  the  appendix  is 
always  found  to  contain  a  fluid  loaded  with  micro-organisms  which  are 
capable  of  causing  purulent  inflammation,  as  the  staphylococcus  or 
streptococcus.  Clinically,  therefore,  all  forms  of  appendicitis  should 
be  considered  due  to  purulent  inflammation  (infectious),  with,  on  the  one 
hand,  escape  of  the  contents  into  the  bowel,  and  natural  relief  of  the 
symptoms;  or,  on  the  other,  complete  obstruction  with  perforation. 
After  removal  of  the  appendix  in  cases  of  recurring  appendicitis,  I 
have  always  found  pus  or  a  muco-purulent  material  which  was  charged 
Avith  streptococci  or  staphylococci,  as  well  as  the  bacillus  coli  communis, 
natural  to  the  intestinal  canal  in  this  region. 

Symptoms  of  the  Attack.  After  exposure  to  cold  rarely,  fre- 
quently after  an  indiscretion  in  diet,  the  patient  is  seized  with  pain, 
referred  to  the  right  lower  quadrant  of  the  abdomen.  It  is  paroxysmal 
in  character,  increasing  in  intensity,  and  may  be  complained  of  as 
colicky.  The  pain  is  usually  such  as  to  require  the  patient  to  take  to 
bed  and  attempt  to  secure  relief  by  local  applications.  The  severity 
of  the  pain  may  be  such  as  to  require  such  treatment,  or  so  slight  that 
the  patient  pays  but  little  attention  to  it.  He  can  even  go  about  his 
business  during  the  time  and  seek  professional  advice  at  the  office  of 
a  physician.  Such  cases  as  these  are  attributed  to  ordinary  cholera 
morbus  or  intestinal  indigestion.  The  attack  may  be  only  moderately 
severe,  particularly  if  there  is  diarrhoea.  With  the  onset  of  the  pain 
vomiting  usually  occurs.  The  bowels  may  be  open  or  they  may  be  con- 
fined. Vomiting  may  not  occur  if  there  is  diarrhoea.  Vomiting  is 
usually  attended  by  some  nausea,  although  this  is  not  marked.     The 


604  SPECIAL  DIAGNOSIS. 

vomiting  is  complete,  there  is  no  retching.  It  occurs  at  intervals,  be- 
tween which  there  is  comparative  comfort.  The  contents  of  the  stomach 
are  ejected,  and  then  mucus.  If  the  patients  are  to  get  well,  vomiting 
does  not  return  unless  excited  by  food.  If  peritonitis  supervenes, 
vomiting  returns  in  the  course  of  two  or  three  days.  If  in  bed,  the 
patient  lies  on  his  back  with  his  right  leg  flexed. 

Even  with  a  mild  degree  of  pain  the  skin  is  hot  and  temperature 
slightly  raised.  In  the  cases  in  which  the  pain  is  more  severe  the 
general  reaction  is  greater.  The  temperature  rises  rapidly  to  102°  to 
103°.  The  skin  is  hot  and  dry,  the  face  flushed.  The  pulse  in  a 
young  adult  rises  to  90  and  95.  It  is  full  and  strong.  On  account 
of  the  pain  there  is  some  restlessness.  In  some  cases  the  patient  com- 
plains more  of  the  fever  than  of  the  pain  after  its  first  severity  has 
subsided.     The  tongue  is  coated  ;  appetite  is  lost. 

On  physical  examination  the  area  which  was  the  seat  of  pain  is  found 
to  be  tender.  When  examined  with  the  tip  of  the  finger  pressing 
firmly,  a  point  of  more  marked  tenderness  can  usually  be  found  on  a 
line  midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
umbilicus.  It  is  known  as  McBurney's  point,  and  is  most  character- 
istic. It  indicates  the  site  of  the  diseased  appendix.  The  swollen 
tender  appendix  may  occasionally  be  palpable.  On  inspection  the 
affected  area  is  slightly  or  may  be  considerably  enlarged.  Compari- 
son must  be  made  with  the  opposite  side.  It  will  be  seen  that  the 
usual  depression  in  front  of  the  anterior  spine,  or  the  cavity  toward 
the  loin,  is  not  so  deep  as  on  the  opposite  side.  In  front  the  surface 
may  be  even  with  the  plane  of  the  ilium.  On  palpation,  in  addition 
to  tenderness  and  pain  at  the  point  previously  indicated,  fulness  and 
enlargement  can  be  distinguished.  There  is  resistance  to  pressure  and 
more  or  less  rigidity  of  the  abdominal  muscles.  On  careful  measure- 
ment the  semi-circumference  will  be  found  in  most  instances  to  be 
larger  than  the  semi-circumference  of  the  opposite  side.  When 
bimanual  palpation  is  performed,  the  left  hand  being  placed  in  the 
loin  behind  and  the  right  over  the  abdominal  surface,  resistance,  indu- 
ration, and  rigidity  can  more  easily  be  detected.  On  percussion  there 
is  change  in  the  note  compared  with  that  of  the  opposite  side,  and 
change  in  the  percussion-note  during  the  course  of  the  disease.  This 
is  particularly  the  case  if  the  symptoms  go  on  to  perforation.  On 
careful  deep  percussion  a  dull  tympanitic  tone  is  elicited,  or  a  distinct 
area  of  dulness  can  be  mapped  out,  but  in  some  instances  the  distended 
caecum  yields  tympany  which  is  greater  than  on  the  opposite  side. 

The  pain  is  usually  referred  to  the  region  above  mentioned.  The 
pain  may  be  in  the  lower  quadrant  on  the  left  side  instead  of  the  right. 
It  is  seen  in  those  cases  in  which  the  appendix  normally  dips  into  the 
pelvis.  It  may  also  be  referred  to  the  bladder  or  genitals,  and  be  at- 
tended with  vesical  tenesmus  and  frequent  micturition.  The  character 
of  the  pain  and  the  bladder  symptoms  are  such  as  to  simulate  an  attack 
of  renal  colic,  with  the  passage  of  sand.  On  account  of  the  locality 
of  the  pain  it  may  be  attributed  to  the  Fallopian  tube  or  ovary  and 
thought  to  be  due  either  to  pain  on  account  of  disease  of  these  organs 
or  to  dysmenorrhoea.     It  is  not  likely  to  be  mistaken  for  the  pain  of 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     605 

dysmenorrhoea  if  the  patient  is  subject  to  pain  at  the  usual  monthly 
period.  If,  however,  the  physiological  and  pathological  affection 
should  take  place  at  the  same  time,  or  the  latter  occur  about  the  time 
of  the  monthly  period,  a  mistake  in  diagnosis  may  occur,  particularly 
as  increased  abdominal  pain  may  cause  a  uterine  discharge.  The  occur- 
rence of  fever  would  exclude  dysmenorrhoea  in  cases  in  which  this 
symptom  was  present.  The  pain  and  leg-flexion  simulate  hip-joint 
disease. 

After  the  first  twenty-four  hours,  during  which  the  above-men- 
tioned symptoms  described  take  place,  the  fever  continues.  There  is 
anorexia,  but  vomiting  occurs  at  longer  intervals  if  at  all.  The  local 
symptoms  continue,  although  modified  usually  by  methods  of  treat- 
ment which  are  applied.  Both  general  and  local  symptoms  frequently 
subside  after  a  free  movement  of  the  bowels,  which  occasionally  takes 
place  spontaneously.  In  other  cases  they  continue  constipated  a  week 
or  ten  days,  and  even  over  a  longer  period. 

After  five  or  six  days  at  the  furthest  fever  subsides,  the  local  dis- 
tention lessens,  the  paroxysms  of  pain  disappear,  and  convalescence 
ensues.  There  may,  however,  be  localized  tenderness  for  a  consider- 
able period  of  time,  and  diarrhoea,  or  at  least  two  or  three  evacuations 
each  day,  for  a  week  or  more.  In  rare  instances  peritonitis  supervenes 
without  the  occurrence  of  perforation.  The  onset  under  these  circum- 
stances is  more  gradual,  but  the  symptoms  are  like  those  of  peritonitis 
under  other  circumstances.  Infection  takes  place  directly  through  the 
appendix. 

When  the  fever  continues,  with  mild  diarrhoea,  intestinal  pain,  and 
flatulency,  the  case  may  be  mistaken  for  typhoid  fever .  The  tempera- 
ture is,  however,  more  remittent  in  character  in  appendicitis,  and  the 
diarrhoea  is  not  characteristic  of  typhoid  fever.  The  eruption  of 
typhoid  does  not  occur,  and  the  symptoms  of  the  typhoid  state  do 
not  ensue.  The  diazo-reaction  and  the  bacteriological  examinatiou  of 
the  stools  may  aid  in  forming  a  conclusion.  The  occurrence  of  bron- 
chitis and  other  symptoms  of  typhoid  would  point  to  the  true  disease. 

Recurrent  Appendicitis.  Frequent  attacks  of  mild  appendicitis 
occur ;  they  may  occur  as  frequently  as  every  three  months,  or  the 
interval  may  be  as  long  as  a  year.  The  attacks  are  similar  to  the 
attacks  just  described,  although  the  duration  is  shorter.  The  local 
symptoms  in  some  instances  are  more  marked,  because  there  has  been 
a  localized  peritonitis  previously.  The  induration  is  greater,  and  dul- 
ness  is  more  characteristic.  In  some  instances  the  attacks  are  compara- 
tively mild,  continuing  but  twenty-four  hours,  and  are  described  as 
attacks  of  colic.  Often  they  have  been  treated  by  the  patient  himself, 
or  by  household  remedies  alone.  The  patient  spends  a  night  in  agony 
with  cramps,  but  the  next  day  follows  his  usual  habits.  It  is  possible 
that  there  has  been  no  fever  with  the  attacks,  but  in  all  cases  of  ap- 
pendicitis which  I  have  seen  fever  has  been  a  constant  accompaniment. 

Appendicitis  with  Perforation.  Before  perforation  takes  place 
the  patient  may  have  had  symptoms  of  the  mildest  form  of  appendi- 
citis for  two  or  three  days,  or  it  may  have  extended  over  a  long 
period  of  time,  without  any  symptoms  but  colicky  pains.      As  obser- 


606 


SPECIAL  DIAGNOSIS. 


vations  are  not  made,  the  presence  of  fever  cannot  in  such  a  case  be 
utilized  as  a  diagnostic  feature.  The  perforation  may  take  place  early 
in  the  course  of  an  acute  attack,  and  result  in  localized  peritonitis 
and  abscess,  or  in  peritonitis.  After  the  characteristic  symptoms  of 
appendicitis  the  symptoms  of  intense  peritonitis  set  in.  The  abdomen 
rapidly  becomes  distended,  the  characteristic  vomiting  ensues,  and  col- 
lapse develops.  Perforation  under  these  circumstances  has  occurred 
within  the  first  twenty-four  hours,  or  at  least  has  not  been  postponed 
beyond  forty-eight  hours.  Local  inflammation  about  the  appendix 
does  not  take  place,  and  the  local  signs  of  an  inflammatory  tumor  are 
not  present,  although  tenderness  at  the  special  point  can  be  elicited. 
If  the  perforation  is  more  gradual,  and  there  has  been  time  for  the 
occurrence  of  local  inflammation  about  the  appendix,  by  which  pus  is 
prevented  from  infecting  the  peritoneum,  or  if  perforation  takes  place 
behind,  in  the  connective  tissue  which  surrounds  the  mass,  in  which 
situation  there  is  always  inflammation,  the  local  signs  of  abscess  or 
inflammatory  tumor  occur.  There  is  swelling  of  the  affected  side;  the 
normal  outline  is  effaced.  The  area  is  indurated,  and  the  early  pro- 
nounced rigidity  gradually  gives  way  to  a  boggy  sensation,  with  the 
appearance  of  oedema  of  the  skin.  This  can  be  elicited  by  pressure 
over  parts   lhat  are   hard   and  resisting,  as  the   spine  of  the  ilium. 


Acute  appendicitis,  with  perforation  and  abscess.    Female,  set.  8.    Operation  on  seventh  day. 

Fluctuation  can  often  be  detected  by  bimanual  palpation.  Dulness  is 
found,  although  in  some  instances  it  may  be  very  slight,  scarcely  an 
appreciable  change  in  pitch.  Both  light  and  deep  percussion  must  be 
performed,  and  compared  with  the  results  of  percussion  in  the  oppo- 
site region.  Examination  per  rectum  may  yield  immediate  results. 
An  induration  may  be  felt  about  the  brim  of  the  pelvis  or  the  rectal 
fossa,  which  fluctuates  and  may  eventually  soften.  With  the  finger  in 
the  rectum,  and  pressure  above,  better  results  may  be  obtained.  If 
the  symptoms  of  peritonitis  do  not  arise,  or  rapid  infection  of  the  sys- 
tem take  place,  the  signs  of  abscess  become  more  and  more  marked. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     607 

The  surface  becomes  reddened,  and  pointing  may  take  place  toward 
the  groin  or  opposite  the  spine.  Sometimes  the  swelling  increases  in 
the  direction  of  the  loin,  and  the  abscess  may  point  in  that  situation. 

As  the  abscess  develops  the  general  symptoms  change.  They  now 
become  the  symptoms  of  suppuration.  The  fever  is  remitting  or  inter- 
mitting. There  may  be  chills.  Sweats  are  common,  and  there  are  loss 
of  appetite  and  diarrhoea.  Until  recently  it  was  customary  to  see 
abscess  develop  in  some  other  situation,  or  symptoms  occur  from  bur- 
rowing of  the  pus  in  various  directions.  It  may  extend  upward  along 
the  back  of  the  colon,  underneath  the  diaphragm,  and  thence  to  the 
pleura  and  lung,  and  be  expectorated.  The  abscess  may  open  into 
the  rectum  or  into  the  bladder.  If  the  local  inflammation  is  virulent 
and  the  symptoms  are  intense,  if  peritonitis  has  not  taken  place,  the 
symptoms  of  septicaemia  may  rapidly  ensue.  This  sometimes  occurs 
quite  early  in  the  disease.  There  may  be  vomiting  and  septic  diar- 
rhoea, and  slight  delirium  at  night.  An  excessively  rapid  and  feeble 
pulse  is  seen  ;  in  one  instance  it  was  irregular.  Extreme  prostration 
ensues,  followed  by  the  symptoms  of  the  typhoid  state. 

Gangrenous  appendicitis  is  most  treacherous.  The  early  symptoms 
are  like  an  acute  attack;  all  symptoms  then  subside,  and  unless  the 
temperature  is  taken  or  the  physical  examination  is  very  painstaking, 
the  patient  is  allowed  to  get  up.  It  is  this  class  of  patients  that  may 
be  without  fever.  In  a  few  days  or  a  week  an  abscess  forms  about  the 
slough,  and  then  the  usual  phenomena  of  suppuration  set  in. 

It  is  clear  that  in  cases  of  appendicitis  we  must  attempt  to  recognize  : 
(1)  the  inflammation  before  perforation  has  taken  place;  (2)  the  occur- 
rence of  perforation  ;  (3)  the  occurrence  of  peritonitis  due  to  either  of 
the  two  conditions  ;  (4)  the  occurrence  of  abscess  (paratyphlitis  and 
perityphlitis);  and  (5)  the  occurrence  of  septicaemia. 

Typhlitis  is  an  inflammation  of  the  csecum  due  to  accumulation  of 
fsecal  or  foreign  substances.  It  may  be  due  to  ulceration.  The  inflam- 
mation may  remain  as  a  localized  enteritis,  or  may  be  followed  by 
ulceration.  In  the  majority  of  cases  the  ulceration  is  due  to  pressure 
by  the  contained  foreign  material  or  fasces.  The  inflammation  occurs 
in  early  life  usually.  The  patients  have  been  subject  to  coustipation. 
The  attack  may  follow  some  error,  in  diet.  There  are  pain  in  the  right 
iliac  fossa,  constipation,  and  nausea.  Moderate  fever  develops.  On 
examination  there  is  fulness  in  the  right  iliac  region,  and  the  right 
thigh  may  be  flexed,  the  caeca!  region  is  tender  to  pressure,  and  a 
doughy,  sausage-shaped  tumor  may  be  outlined.  The  more  severe 
symptoms  last  two  or  three  days.  Local  tenderness  may  continue  a 
week  or  even  longer.  The  tumor  gradually  disappears.  If  ulcera- 
tion takes  place,  inflammation  about  the  csecum  ensues.  An  abscess 
forms  gradually  in  the  flank.  Perityphlitis  is  the  term  applied  to  this 
secondary  abscess,  although,  as  the  term  has  been  confused  with  para- 
typhlitis, it  had  better  not  be  used  in  this  connection. 

Appendicitis  must  be  distinguished  from  perinepliritic  abscess  and 
the  abscess  which  follows  perforation  of  the  intestine  or  coecam  at  this 
point.  Perinephritis  can  scarcely  be  distinguished  unless  there  has 
been  a  previous  history  of  renal  calculus  and  pronounced  evidence  of 


608  SPECIAL  DIAGNOSIS. 

disease  of  that  organ  preceding  the  formation  of  the  abscess.  Peri- 
ccecal  abscess  follows  the  stercoral  typhlitis  which  occurs  as  the  result 
of  cancer  in  the  course  of  the  large  intestine.  The  history  of  the  case 
points  to  the  true  nature  of  the  disease.  Abscess  may  occur  behind 
the  caecum  in  cases  of  caries  of  the  vertebra?  and  in  some  rare  instances 
of  empyema  in  which  the  pus  has  dissected  downward.  Hip-joint  dis- 
ease must  be  distinguished  from  appendicitis.  The  leg  is  flexed,  the 
patient  complains  of  pain  about  the  region  of  the  hip  ;  unless  careful 
observation  has  been  made  in  the  beginning  of  the  attack,  the  early 
march  of  appendicitis  may  not  be  recognized.  The  two  are  confounded 
after  abscess-formation.  The  flexed  leg  of  appendicitis  can  be  extended 
under  ether,  and  examination  then  shows  the  joint  to  be  free  from 
disease. 

Fenwick  says  that  acute  tubercular  peritonitis  may  be  confounded 
with  perforation  of  the  appendix.  In  both  there  may  be  both  pain 
and  tenderness  in  the  hypogastrium,  dulness  on  percussion,  and  fever. 
In  tubercular  peritonitis  the  onset  is  more  gradual,  the  pain  and  ten- 
derness more  general,  there  is  no  distinct  tumor  or  increased  tension 
in  the  hypogastrium.  If  there  is  dulness  on  percussion,  the  line  gen- 
erally varies  with  the  position  of  the  patient.  Diarrhoea  is  urgent, 
and  there  are,  in  most  cases,  some  signs  of  consolidation  of  the  lungs. 
The  absence  of  tumor  in  the  right  iliac  region  and  in  front  of  the  rec- 
tum is  the  chief  point  of  distinction;  for  when  perforation  occurs  in 
phthisical  subjects  there  is  generally  very  slight  pain,  and  severe  diar- 
rhoea is  often  the  only  prominent  symptom.  The  appendicitis  itself 
may  be  of  tuberculous  origin. 

Abscess  about  the  head  of  the  caecum  is  due  (1)  to  appendicitis,  of 
which  sufficient  mention  has  been  made;  (2)  to  perforation  of  the 
caecum  on  account  of  typhlitis;  (3)  to  perforation  on  account  of  cancer 
of  the  intestine;  (4)  abscess  secondary  to  kidney  disease,  perinephritic 
abscess;  (5)  to  abscess  secondary  to  disease  of  the  vertebrae.  The 
physical  signs  are  those  of  abscess  due  to  perforation  of  the  appendix. 
The  symptoms  are  the  local  symptoms  of  abscess  and  the  general 
symptoms  of  suppuration. 

Tuberculosis  of  the  Intestine. 

The  disease  is  usually  secondary  to  chronic  tuberculosis,  but  may  be 
primary,  especially  in  children.  The  symptoms  are  usually  those  of 
diarrhoea,  and  in  the  primary  form  this  is  associated  with  general  ema- 
ciation, which  advances  rapidly,  and  with  anaemia.  Fever  of  the 
intermittent  or  remittent  type  is  present.  There  is  meteorism;  the 
abdomen  is  much  distended,  but  eventually  becomes  contracted.  The 
mesenteric  glands  can  be  made  out  along  the  spinal  column,  and  the 
intestines  may  become  bunched  into  a  mass,  yielding  a  dull  tympany 
on  percussion  in  the  centre  of  the  abdomen.  The  diarrhoea  is  attended 
with  colicky  pains.  The  diagnosis  is  based  upon  the  rapid  emaciation, 
irregular  fever,  enlargement  of  the  mesenteric  glands  in  a  patient, 
usually  a  child,  who  had  probably  been  exposed  to  tuberculous  infec- 
tion.    In  one  of  my  cases  the  child,  aged  four  years,  ate  of  the  same 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     609 

food,  using  the  same  utensils,  as  a  brother,  a  lad  of  twenty-two  years, 
dying  of  pulmonary  tuberculosis.  The  child  was  constantly  with  the 
brother.  The  remainder  of  the  family,  eight  in  number,  remained  in 
perfect  health,  and  were  all  of  good  physique.  The  elder  brother 
became  infected  by  association  with  tuberculous  subjects  in  improper 
quarters  away  from  home. 

Cancer  of  the  Intestines. 

The  disease  usually  occurs  late  in  life,  and  is  associated  with  progress- 
ive emaciation  and  cachexia.  There  may  not  be  any  symptoms  save 
general  failure  of  health  until  the  sudden  occurrence  of  obstruction  of  the 
bowel.  The  symptoms  vary  with  the  position  of  the  carcinoma  and 
the  direction  of  growth  of  the  tumor.  In  some  instances  with  the 
general  symptoms  there  may  be  irregular  -pain  in  the  abdomen,  with 
irregularity  of  the  stools.  The  tumor  may  be  detected  if  the  small 
intestine  is  involved.  Its  detection  is  facilitated  by  having  the  patient 
get  on  the  hands  and  knees  and  palpating  the  abdomen  in  this  position, 
and  by  clearing  out  the  colon  by  a  large  enema.  On  auscultation  the 
water  may  be  heard  to  enter  the  dilated  colon  beyond  the  tumor,  the 
sound  resembling  the  deglutition-murmur  at  the  cardiac  end  of  the 
stomach.  If  the  tumor  is  situated  in  the  lower  colon,  pain  in  the  sacral 
region,  resembling  sciatica,  may  be  complained  of  ;  if  the  caecum  or  the 
sigmoid  flexure  is  the  seat  of  disease,  a  tumor  is  usually  detected. 
Wherever  the  situation,  the  tumor  found  is  tender,  usually  lying  in 
the  axis  of  the  intestine — movable  if  in  the  small  intestine,  fixed  if 
in  the  caecum  or  the  sigmoid  flexure.  In  the  latter  location  the  tumor 
may  be  felt  per  rectum.  One  notable  characteristic  is  that  it  may  be 
palpable  some  days  and  not  be  present  at  other  times.  The  position 
and  size  may  vary  from  day  to  day,  although  it  is  always  hard  and 
knotty,  not  doughy.  Constipation  is  characteristic  of  most  of  the 
cases.  It  may  alternate  with  diarrhoea.  The  stools  are  frequently 
ribbon-shaped,  or  they  may  pass  in  scybalous  masses,  or  large  or  small 
amounts  of  blood,  chiefly  the  latter,  are  passed  with  pus  or  mucus ; 
sometimes  masses  resembling  cancer  can  be  found  in  the  stool.  If  the 
tumor  is  in  the  rectum,  there  is  great  difficulty  in  def aecation ;  the  act 
is  attended  by  pain.  Later  the  pain  becomes  constant,  and  may  radiate 
to  the  hip  or  the  genitalia.  Sometimes  this  pain  is  the  only  symptom 
complained  of.  Mucus  and  blood  appear  in  the  stools,  the  bowels 
being  alternately  confined  and  loose.  Paralysis  of  the  sphincter  ani 
may  take  place  with  incontinence.  A  tumor  may  be  felt  per  rectum 
or  be  seen  through  the  rectal  speculum.    It  may  be  a  hard  knotty  mass. 

The  diagnostic  symptoms  are  :  (1)  The  general  symptoms  of  cancer. 
(2)  The  tumor.  (3)  The  occurrence  of  constipation  which  leads  to 
complete  obstruction,  or  obstipation,  alternating  with  diarrhoea.  Blood 
in  the  stools,  with  alteration  in  the  shape  of  the  faeces,  is  significant. 

Amyloid  Degeneration  of   the  Intestines. 

The  symptoms  are  those  of  diarrhoea,  persistent  but  mild  in  char- 
acter, associated  with  symptoms  of  amyloid  disease  in  other  organs. 

39 


610  SPECIAL  DIAGNOSIS. 

With  enlargement  of  the  liver  and  spleen  changes  in  the  urine  due  to 
amyloid  disease  are  present.  The  occurrence  of  these  symptoms  in  a 
patient  with  syphilis,  or  especially  in  a  child  with  bone  disease  or 
tuberculosis,  points  to  the  nature  of  the  case. 

Dilatation  of  the  Colon. 

The  dilatation  takes  place  temporarily  in  constipation  with  obstruc" 
tion.  In  rare  cases  it  may  become  permanent.  The  distention  of  the 
abdomen  is  enormous.  It  may  begin  in  childhood  and  continue  through 
adult  life.  Congenital  obstruction,  the  eating  of  oatmeal  or  similar 
food,  with  attendant  constipation,  leads  to  distention.  The  bowels 
are  constipated.  The  constipation  may  continue  for  several  weeks, 
during  which  period  there  is  increasing  clulness  in  the  tract  of  the 
colon,  with  fsecal  tumors  distinguished  by  palpation.  The  constipation 
is  relieved  by  diarrhoea,  which  may  continue  for  two  or  three  days, 
during  which  enormous  amounts  of  fseces  are  passed.  It  may  be  pre- 
ceded by  vomiting  of  a  fsecal  character.  After  the  bowels  are  open  the 
distention  continues,  the  dulness  being  replaced  by  tympany. 

Enteroptosis. 

This  disease  or  physical  condition,  called  sometimes  Glenard' s  disease, 
after  the  physician  who  first  called  attention,  in  1885,  to  its  existence, 
has  received,  of  late,  much  study.  It  is  characterized  by  falling  down 
or  descent  of  a  number  of  the  abdominal  organs.  This  occurs  on 
account  of  relaxation  of  the  supporting  ligaments,  the  number  of  which 
Glenard  puts  at  six.  This  relaxation  is  largely  due  to  a  flabbiness  and 
hence  lack  of  support  of  the  abdominal  wall;  or  to  strain  from  undue 
physical  exertion  ;  or  to  the  abuse  of  cathartics  ;  or  possibly  to  injury. 
It  is  far  more  common  in  females  who  have  borne  children.  It  may 
be  the  result  of  feeble  muscle-tone,  following  prolonged  illness.  The 
degree  of  descent,  and  hence  the  severity  of  the  symptoms,  may  vary 
from  slight  displacement  of  one  or  two  organs  to  that  of  the  large 
intestine,  the  stomach,  the  liver,  the  spleen,  and  the  right  kidney  (some- 
times both).  In  moderate  cases  but  two  of  the  ligaments  are  relaxed 
— the  ligamentum  colico-hepaticum  and  the  ligamentum  gastro-colicum; 
in  the  more  severe  all  are  affected. 

Symptoms.  The  objective  symptoms  are  due  to  the  slight  displace- 
ment, and  are  either  purely  physical  or  are  from  the  alteration  in  the 
function  of  the  .stomach  and  the  intestines. 

The  subjective  symptoms  are  due  to  the  same  cause.  The  displace- 
ment gives  rise  to  local  symptoms  of  weight,  heaviness,  and  abdominal 
distress,  amounting  in  some  instances  -to  pain,  especially  when  in  the 
upright  position,  and  to  protracted  and  pronounced  neurasthenia. 
Second,  we  have  the  subjective  symptoms  seen  in  dyspepsia,  gastritis, 
gastric  dilatation,  and  intestinal  atony,  while  the  neurasthenic  symp- 
toms are  more  aggravated. 

The  earliest  objective  symptoms  are  :  (1)  Pulsation  of  the  abdom- 
inal aorta  ;  (2)  a  linear  tumor  or  band  about  midway  between  the 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     611 

xiphoid  cartilage  and  the  umbilicus,  extending  transversely  from  four 
to  six  inches  in  length  ;  (3)  gastroptosis,  or  descent  of  the  stomach  ; 
(4)  movable  right  kidney.  Later,  the  liver  may  fall  from  one  to  four 
inches,  the  spleen  become  palpable,  and  the  left  kidney  movable.  The 
transverse  tumor  above  mentioned  was  held  by  Glenard  to  be  the 
thickened  transverse  colon.  Ewald,  however,  seems  to  have  demon- 
strated that  it  is  the  pancreas.  The  displacement  of  the  viscera  is 
recognized  by  the  methods  previously  detailed  for  physical  examina- 
tion of  the  various  organs.  The  patient  must  always  be  examined  in 
the  erect  as  well  as  in  the  recumbent  position.  Care  must  be  taken  to 
distinguish  gastric  dilatation  from  gastric  descent.  This  can  be  done 
by  careful  percussion  after  inflation  with  air,  by  gastric  diaphony,  by 
measurement  with  a  sound,  and  with  fluids.  Glenard  laid  much  stress 
upon  the  splashing  sound.  This  may  or  may  not  be  present;  it  may 
be  of  gastric  or  intestinal  origin;  it  does  not  depend  upon  the  displace- 
ment as  much  as  upon  the  occurrence  of  gastric  dilatation.  It  occurs 
in  other  affections. 

An  objective  sign  of  diagnostic  value,  attention  to  which  has  been 
called  by  Treves,  is  the  relief  the  patient  experiences  when  the  lower 
half  of  the  abdomen  is  supported  by  a  belt  or  by  the  hands  of  the 
patient,  when  in  the  upright  position. 

The  objective  signs  of  gastric  origin  depend  upon  functional  or 
organic  disease  of  that  organ.  We  may  have,  on  the  one  hand,  only 
the  perverted  gastric  secretion  and  digestion  that  go  with  gastric 
neuroses ;  on  the  other  hand,  we  may  have  the  perverted  gastric  secre- 
tion of  gastritis,  gastric  atrophy,  or  dilatation,  and  the  evidences  of 
difficult  digestive  motor  and  absorptive  power  of  these  affections. 

The  subjective  symptoms  also  depend  upon  the  functional  or  orgauic 
changes  in  the  stomach  and  intestines,  upon  the  displacement  of  the 
organs,  with  or  without  the  above,  or  upon  the  associate  physical  mus- 
cular condition  of  the  individual  and  the  state  of  the  nervous  system. 

Glenard  divided  the  progress  of  the  subjective  symptoms  into  three 
periods:  In  the  first  there  is  gastric  atony,  when  the  patient  experi- 
ences weight  and  burning  after  eating  ;  a  short  period  of  wakefulness 
about  two  o'clock  a.m.;  a  loose  stool  in  the  morning;  loss  of  strength. 
In  the  second  period  the  patient  cannot  eat  fats  and  starches,  and  the 
subjective  symptoms  arise  late  in  the  period  of  digestion.  A  dragging 
sensation,  emptiness,  occurs  about  three  hours  after  meals.  The  patient 
awakens  at  two  o'clock  a.m.,  and  remains  awake  for  two  or  three  hours. 
Constipation,  at  times  alternating  with  diarrhoea,  is  present.  There  is 
continued  loss  of  strength,  and  a  tired  feeling  is  complained  of  on  rising 
in  the  afternoon.  In  the  third  period  the  symptoms  of  neurasthenia 
are  most  pronounced.  The  patient  is  emaciated  and  complains  of  a 
constant  weight  and  of  cramps  in  the  stomach.  Constipation  is  obsti- 
nate, and  the  stools  are  scybalous  and  mucous.  The  patient  is  much 
prostrated  and  suffers  much  from  sleeplessness.  The  constipation  is 
aggravated  by  aperients  and  the  intestinal  distress  added  to  by  them. 
Euemata  must  be  resorted  to  to  relieve  the  symptoms.  Intestinal 
catarrh  or  membranous  enteritis  is  very  likely  to  follow. 

Pain  throughout  the  abdomen,  especially  when  walking  about  or  in 


612  SPECIAL  DIAGNOSIS. 

the  erect  posture,  is  frequently  complained  of.  Some  authorities  speak 
of  tenderness  on  pressure  over  the  solar  plexus  and  of  tender  points 
along  the  vertebra. 

The  disease  is  overlooked  and  the  symptoms  attributed  to  neuras- 
thenia.    It  is  difficult  often  to  estimate  which  of  the  two  preponderates. 

Diseases  of  the  Rectum. 

Consideration  of  rectal  lesions  belongs  to  the  surgeon.  It  is  proper, 
however,  to  insist  upon  the  very  frequent  deleterious  effect  of  such 
lesions  in  neurasthenic  subjects.  Indeed,  the  bleeding  which  attends 
hemorrhoids  may  be  sufficient  to  lead  to  profound  anaemia,  upon  which 
neurasthenia  may  readily  develop.  The  local  suffering  due  to  rectal 
fissure,  or  prolapse,  may  aggravate  any  tendency  to  the  state  of  neu- 
rasthenia, or  aid  materially,  with  other  conditions,  to  fasten  it  more  firmly 
upon  the  system.  In  cases  of  anaemia,  of  neurasthenia,  of  the  gastric 
neuroses,  of  debility,  or  prostration,  the  cause  of  which  cannot  be  ascer- 
tained, the  rectum  should  be  examined.  The  appearances  of  hemor- 
rhoids and  other  rectal  affections  are  described  in  works  on  surgery. 
Hemorrhoids,  ulcers,  fistula,  and  carcinoma  are  to  be  sought  for  in 
abdominal  affections. 

Inspection  and  palpation  are  necessary.  The  symptoms  are  those  of 
local  pain,  tenesmus,  and  frequently  hemorrhage.  The  pain  follows 
a  movement  of  the  bowels.  There  may  be  a  feeling  as  of  a  foreign 
body  in  the  rectum,  with  some  itching  and  burning  about  the  anus. 
The  pain  may  be  so  severe  as  to  inhibit  defalcation.  The  timid  sub- 
jects will  not  endure  the  act;  in  consequence  they  suffer  from  vertigo, 
headache,  tympanites,  and  symptoms  of  gastro-intestinal  disorder.  In 
some  instances  there  is  chronic  catarrh  of  the  rectum  with  discharge  of 
small  stools  containing  mucus  or  pus  streaked  with  blood.  Cases  occur 
in  which  hemorrhage  is  the  only  symptom,  the  constant  recurrence  of 
which  leads  to  grave  constitutional  results.  Hemorrhoids  are  the 
lesions  for  which  the  rectum  is  most  frequently  examined.  They,  as 
well  as  other  lesions,  are  of  diagnostic  significance  in  affections  beyond 
the  rectum.  Thus,  in  all  forms  of  portal  congestion  internal  hemor- 
rhoids are  of  frequent  and  constant  occurrence,  and  when  found  in  the 
toper  may  be  one  of  the  first  indications  of  cirrhosis  of  the  liver. 
Rectal  fissure  is  not  of  much  diagnostic  significance.  The  finding  of 
a  small  cancer,  the  symptoms  of  which  may  be  those  of  hemorrhoids, 
may  explain  emaciation  and  the  development  of  cachexia.  Ulcer  of 
the  rectum  may  be  due  to  syphilis,  cancer,  or  tuberculosis.  A  fistula 
is  often  tuberculous.  The  rectum  must  be  examined  in  cases  of  pyae- 
mia, particularly  of  the  portal  variety,  when  jaundice,  enlargement  of 
the  liver,  and  hectic  are  present.  Local  rectal  disease  may  cause 
pylephlebitis. 

Diseases  of  the  Peritoneum.     Peritonitis. 

Inflammation  of  the  peritoneum  may  be  acute  or  chronic.  It  may 
be  general  or  localized.      Acute  inflammation  is  rarely  primary;    it 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     613 

may  occur  in  the  later  stages  of  chronic  Bright' s  disease,  or  other 
dyscrasia,  without  apparent  cause.  If  it  follows  exposure  to  cold,  or 
trauma,  it  is  called  traumatic  peritonitis.  It  is  due  in  the  large 
majority  of  cases  to  extension  from  organs  which  the  peritoneum  covers, 
or  to  perforation  of  one  of  the  abdominal  organs.  In  the  first  instance 
it  may  follow  inflammation  of  any  portion  of  the  gastro-intestinal 
tract,  of  the  pelvic  viscera,  and  suppurative  inflammation  of  the  spleen 
and  liver  and  of  the  pancreas.  In  all  instances  the  primary  inflam- 
mation in  the  organs  mentioned  is  due  to  some  micro-organism,  as  the 
staphylococcus,  the  streptococcus,  or  the  bacillus  coli  communis,  and  the 
peritoneal  inflammation  to  subsequent  extension  of  the  infection.  In  a 
peritonitis  that  occurs  from  perforation  the  element  of  infection  also 
plays  an  important  part,  as  in  ulcer  of  the  stomach  or  bowels.  In  inflam- 
mation of  the  gall-bladder  perforation  may  take  place  with  resulting 
peritonitis.  Abscess  in  the  liver,  spleen,  or  kidneys,  bursting  into  the 
peritoneum,  also  leads  to  general  peritonitis.  The  most  common  forms, 
however,  are  due  to  appendicitis  or  disease  of  the  Fallopian  tubes. 
Acute  peritonitis  may  also  occur  in  cases  of  tuberculosis  by  direct 
infection. 

Symptoms.  The  onset  of  acute  peritonitis  depends  in  a  measure  upon 
the  cause.  When  there  is  perforation  or  infection  the  onset  is  sudden; 
chilly  feelings  or  a  rigor  occur,  with  intense  pain  m  the  abdomen.  If 
at  first  localized,  the  pain  rapidly  becomes  general,  is  constant  and 
increases  in  exacerbations,  is  very  intense,  aggravated  by  movements 
and  by  pressure.  The  patient  lies  on  the  back  with  the  legs  drawn 
up.  The  dorsal  decubitus  is  assumed  in  order  that  the  tension  of  the 
abdominal  muscles  may  be  relieved.  The  location  of  the  pain  depends 
upon  the  seat  of  primary  infection  ;  this  is  usually  in  the  right  or  left 
lower  quadrant,  more  marked  about  the  tubes  or  the  appendix.  In 
perforation  of  an  ulcer  of  the  stomach  the  pain  may  be  complained 
of  in  the  back,  or  referred  to  the  chest  or  shoulders. 

Physical  Examination.  On  palpation  the  abdomen  is  extremely  sen- 
sitive. The  patient  is  unable  to  bear  the  weight  of  clothing  or  external 
applications.  The  abdomen  gradually  becomes  distended,  and  is  tym- 
panitic on  percussion.  The  distention  may  become  so  great  as  to  push 
up  the  diaphragm  and  interfere  with  the  respirations,  so  that  they  are 
shallow,  and  may  dislocate  the  heart  so  that  the  apex-beat  is  seen  in 
the  fourth  interspace.  The  splenic  dulness  may  be  obliterated  entirely 
and  the  liver-dulness  reduced.  It  is  said  that  in  some  instances  this 
may  be  obliterated,  although  recent  observations  affirm  that  such  oblit- 
eration only  occurs  in  the  anterior  portion  of  the  abdomen.  Liver- 
dulness  persists  in  the  axillary  region,  though  diminished  in  extent. 
This  obliteration  could  only  take  place  in  perforative  peritonitis.  Osier 
point-  out  that  in  pneumo-peritoneum  from  perforation  the  anterior  he- 
patic dulness  may  be  obliterated,  although  dulness  in  the  lateral  region 
continues  on  account  of  the  effusion  of  fluid.  If  a  patient  with  gas 
in  the  peritoneum  is  turned  on  the  left  side,  a  clear  note  is  heard  beneath 
tihe  seventh  and  eighth  ribs  (hepatic  region).  The  abdominal  muscles 
are  often  rigidly  contracted.  In  some  cases,  usually  when  the  inflam- 
mation is  due  to  the  streptococcus,  there  is  not  much  distention  of  the 


614  SPECIAL  DIAGNOSIS. 

abdomen,  or  it  may  be  flattened  entirely  with  board-like  rigidity.  In 
these  instances  pain  is  not  so  marked  and  tenderness  may  not  be  com- 
plained of. 

The  respirations  are  hurried  and  the  superior  thoracic  type  of  breath- 
ing is  seen  because  the  action  of  the  diaphragm  is  painful.  The  act 
of  speaking  or  coughing  increases  the  pain,  and  the  patients  are  unable 
to  take  a  full  breath  without  suffering.  With  the  occurrence  of  pain  and 
local  signs  vomiting  usually  sets  in.  It  is  painful  and  at  first  is  com- 
plete, the  contents  of  the  stomach  being  ejected  and  then  a  yellowish 
bile-stained  fluid;  later  the  vomit  becomes  greenish  in  color.  Com- 
plete vomiting  is  replaced  by  simple  regurgitation  of  fluid,  so  that  on 
the  slightest  motion  of  the  patient,  or  on  taking  a  small  amount  of 
fluid,  the  characteristic  greenish-colored  fluid  is  regurgitated  without 
action  of  the  diaphragm.  This  may  be  almost  continuous  for  twenty- 
four  to  forty-eight  hours.  The  tongue  is  at  first  furred,  but  later 
becomes  dry  and  often  is  cracked  and  red.  The  bowels  are  constipated. 
They  may  be  loose  at  first,  but  constipation  is  characteristic.  The 
intestines  are  paralyzed  from  overdistention  and  from  oedema  of  the 
walls  due  to  inflammation. 

The  general  symptoms  are  marked.  After  the  chill  the  temperature 
rises  to  104°  or  105°.  In  septic  cases  it  continues  at  this  point,  or 
may  rise  to  a  greater  height.  If  cases  progress  rapidly,  a  temperature 
of  105°  or  106°  on  the  second  or  third  day  is  not  uncommon.  In 
other  cases  after  the  initial  rise  the  subsequent  elevation  is  not  so 
great,  but  there  is  not  much  difference  between  morning  and  evening 
temperature  unless  there  is  an  abscess. 

The  urine  is  scanty;  micturition  may  be  frequent  and  painful,  par- 
ticularly if  the  iuflammation  began  in  the  pelvic  organs.  The  urine 
usually  contains  a  large  amount  of  indican  in  the  suppurative  form. 

The  appearance  of  the  patient  at  the  height  of  the  disease  is  charac- 
teristic. The  expression  is  anxious,  the  face  is  pinched,  the  eyes  sunken. 
Vomiting  causes  wasting.  The  collapse  is  marked,  with  the  character- 
istic facies  previously  described  (see  Expression).  The  pulse  is  rapid 
and  feeble  and  soon  becomes  thready,  ranging  from  110  to  150.  In 
the  first  stages  it  may  be  small  and  hard.  Attention  has  been  called 
frequently  to  the  peculiar  wiry  pulse  of  the  early  stage  of  peritonitis. 

In  severe  cases  death  may  take  place  in  thirty-six  to  forty-eight 
hours.  Usually  a  fatal  termination  does  not  take  place  for  five  or  six 
days,  and  may  be  delayed  longer.  The  vomiting  persists,  collapse 
with  falling  temperature  ensues,  the  pulse  becomes  rapid  and  thready. 
Throughout  the  entire  attack,  unless  symptoms  of  septicemia  are 
marked,  the  mind  is  clear.  The  patient  dies  of  paralysis  of  the  heart. 
Septicemic  symptoms  are  indicated  by  a  dusky  color  of  the  face,  rapid 
and  irregular  pulse,  slight  delirium,  dry  brown  tongue,  and  other 
evidences  of  the  typhoid  state. 

If  the  cases  are  prolonged,  some  effusion  may  take  place  into  the 
peritoneal  cavity.  Dulness  is  noted  in  the  flank,  and  if  it  is  possible 
to  move  the  patient,  it  alters  with  the  position.  If  recovery  takes 
place,  particularly  in  tuberculous  cases,  the  affection  may  become  cir- 
cumscribed and  be  indicated  by  dulness  which  is  not  movable. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     615 

Diagnosis.  It  is  essential  in  making  a  diagnosis  to  ascertain;  if 
possible,  the  primary  source  of  the  infection  or  inflammation.  To 
determine  this  we  inquire  the  age,  sex,  and  history  of  previous  disease  of 
the  patient.  In  young  male  adults  appendicitis  is  first  to  be  thought  of; 
in  females  inflammation  of  the  pelvic  organs.  In  chlorotic  subjects,  if 
the  pain  is  high  up,  a  history  of  ulcer  of  the  stomach  must  be  inquired 
for.  Later  in  life,  particularly  if  there  has  been  jaundice,  the  possible 
history  of  frequent  attacks  of  gallstones  and  of  hepatic  disturbances 
must  be  ascertained.  All  forms  of  intestinal  obstruction  must  be 
sought  for.  Frequently,  however,  a  definite  cause  cannot  be  ascer- 
tained. If  it  occurs  in  the  course  of  typhoid  fever,  it  is  usually  due 
to  perforation,  but  the  occurrence  of  pain  may  not  be  complained  of 
on  account  of  the  mental  state  of  the  patient.  Under  other  circum- 
stances the  symptoms  cannot  be  overlooked. 

Acute  peritonitis  must  be  distinguished  from  entero-colitis.  The 
distinction  is  not  usually  difficult  if  attention  is  paid  to  the  develop- 
ment of  the  case.  The  pain  is  not  so  severe  in  entero-colitis;  it  is 
more  colicky  in  character.  The  general  tenderness  is  not  so  great  as 
in  peritonitis,  and  the  distention  does  not  interfere  with  respiration 
to  such  a  marked  degree.  Diarrhoea  is  more  common  in  entero-colitis; 
collapse,  if  present,  is  not  so  pronounced. 

Obstruction  of  the  Bowel.  The  diagnosis  is  difficult  in  the  absence 
of  a  distinct  history,  but  in  peritonitis  we  do  not  have  stercoraceous 
vomiting.  The  tympanites  is  more  general,  the  pain  is  more  general, 
and  the  vomiting  is  different  unless  the  peritonitis  is  due  to  obstruc- 
tion. A  tumor,  if  present,  may  point  to  the  true  nature  of  the  case, 
and,  if  there  is  any  discharge  from  the  rectum,  invagination  may  be 
the  exciting  cause. 

Peritonitis  is  simulated  by  a  condition  to  which  the  name  hysterical 
peritonitis  has  been  applied.  It  occurs  in  hysterical  subjects,  and  every 
feature  of  the  true  form  is  imitated.  The  mode  of  onset,  the  decubi- 
tus, the  difficulty  in  micturition,  and  the  local  distention  and  tender- 
ness of  the  abdomen  are  characteristic  of  both.  In  a  few  cases  which 
we  have  seen  the  vomiting  is  not  of  the  nature  of  true  peritonitis, 
either  in  the  mode  of  ejection  or  the  character  of  the  fluid.  It  must 
not  be  forgotten  that  even  the  temperature  may  be  elevated  and  collapse 
take  place  in  the  hysterical  form.  In  the  cases  which  I  have  seen 
the  abdominal  facies  does  not  develop,  while,  on  the  other  hand,  the 
fades  of  hysteria,  with  the  self-interest  which  the  patient  exhibits, 
and  the  precision  with  which  symptoms  are  narrated,  coupled  with 
emotional  or  other  manifestations  of  hysteria,  point  to  the  true  nature 
of  the  affection.  Other  symptoms  of  hysteria  may  arise.  The  case 
is  judged  by  the  history  of  these  associated  manifestations  and  the  per- 
manent stigmata  of  the  disease.  There  is  always  a  positive  absence  of 
cause,  and  of  disease  in  any  of  the  abdominal  viscera.  Sometimes  in 
these  cases,  if  the  attention  of  the  patient  is  diverted,  the  tenderness  on 
pressure  may  not  be  complained  of.  I  am  not  familiar  with  the  results 
of  examination  of  the  urine  in  this  form  of  peritonitis.  Indican  should 
not  necessarily  be  increased,  as  we  find  it  to  be  in  acute  suppurative 
peritonitis. 


616  SPECIAL  DIAGNOSIS. 

Rheumatism  of  the  Abdominal  Walls.  There  is  absence  of  a  history 
of  sudden  acute  pain  followed  by  general  pain.  The  fever  is  not  so 
great.  The  respirations  are  not  interfered  with,  the  pulse  is  not  so 
rapid,  and  symptoms  of  collapse  do  not  supervene.  A  rheumatic  phar- 
yngitis or  inflammation  of  muscles  in  some  other  portion  of  the  body 
may  occur  simultaneously.  Acute  hemorrhagic  pancreatitis  may  simu- 
late peritonitis  in  the  sudden  intensity  of  pain  and  the  occurrence  of 
shock. 

Local  Circumscribed  Peritonitis.  The  causes  of  localized  peritonitis 
are  those  of  general  peritonitis — that  is,  extension  of  inflammation 
from  neighboring  viscera,  or  perforation  of  the  viscera.  In  the  latter 
instance  the  inflammation  does  not  become  general,  because  of  rapid 
local  inflammation  shutting  off  the  perforated  area  from  the  general 
cavity  of  the  peritoneum.  Local  peritonitis  of  mild  degree  and  local 
or  circumscribed  peritonitis  with  suppuration  are  therefore  found  in  the 
neighborhood  previously  indicated,  from  which  a  general  peritonitis 
may  develop.  The  inflammation,  however,  if  retained  by  a  limiting 
wall,  may,  after  suppuration  has  taken  place,  gradually  extend  and  the 
pus  burrow  in  various  directions.  In  such  cases  of  localized  peritonitis 
as  may  exist  in  the  upper  half  of  the  abdomen,  a  sub-diaphragmatic 
abscess  may  form,  or  an  abscess  containing  air  and  pus,  known  as  pyo- 
pneumothorax subphrenicus.  If  the  inflammation  is  secondary  to  dis- 
ease of  the  pancreas,  it  may  be  limited  to  the  lesser  peritoneum  and 
cause  the  physical  signs  of  effusion  in  this  cavity  (see  Disease  of  the 
Pancreas).  Sub-diaphragmatic  abscess  is  not  limited  to  the  lesser 
peritoneum.  It  can  only  be  recognized  by  the  history  of  previous 
disease  on  account  of  which  perforation  may  take  place,  and  by  the 
general  symptoms  of  abscess.  If  the  abscess  is  on  the  left  side,  there 
is  an  extension  of  dulness  upward  toward  the  scapula,  the  lower  limit 
of  the  lungs  in  health  ceasing  at  the  eighth  or  ninth  interspace.  There 
may  also  be  dulness  in  the  axillary  region.  If  the  abscess  is  on  the 
right  side,  it  may  simulate  enlargement  of  the  liver,  and  be  character- 
ized by  marked  increase  in  dulness  anteriorly,  laterally,  or  posteriorly. 
Localized  peritonitis  in  the  lower  half  of  the  abdomen  is  due  to  disease 
of  the  vermiform  appendix,  or  to  disease  of  the  Fallopian  tubes.  The 
localized  signs  are,  first,  those  of  pain  and  tenderness  ;  second,  the 
development  of  tumor. 

Chronic  Peritonitis.  The  symptoms  of  diffuse  peritonitis,  chronic  in 
course,  may  follow  the  acute,  or  may  occur  in  the  course  of  tubercu- 
losis. The  intestines  and  peritoneum  are  matted  together.  General 
pain  and  tenderness,  with  a  prolonged  period  of  ill  health,  attend  the 
diffuse  form  (see  Tuberculous  Peritonitis).  In  the  chronic  forms, 
particularly  if  there  is  considerable  fibrous  proliferation  independent 
of  cancer  and  tubercle,  the  abdomen  becomes  retracted,  the  muscles 
rigid,  the  note  over  the  abdomen  modified  or  dull  tympanitic.  The 
modification  may  be  detected  in  the  upper  half  of  the  abdomen  par- 
ticularly, and  especially  over  the  liver.  Sometimes  a  fremitus  can  be 
felt.  The  patients  are  under  weight  and  without  strength.  The  pain 
may  continue  a  long  time.  It  finally  results,  at  least  clinically,  in  such 
compensation  that  the  patient  is  able  to  continue  his  usual  occupation. 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     617 

Localized  bands  form,  and  may  cause  local  sensations  of  a  dragging 
character,  or  pain  with  drawing  or  pulling  sensations,  but,  save  the 
local  symptoms,  these  are  not  serious,  unless  it  should  happen,  as  has 
been  seen  in  intestinal  obstruction,  that  coils  of  intestine  are  twisted 
about  the  bands  or  caught  in  them,  thus  leading  to  obstruction. 

Ascites. 

Ascites  is  the  accumulation  of  fluid  in  the  peritoneal  cavity.  The 
causes  may  be  local  or  general.  It  occurs,  first,  in  simple,  cancerous, 
or  tuberculous  inflammation  of  the  peritoneum;  second,  in  portal 
obstruction  from  disease  of  the  liver,  as  cirrhosis,  or  disease  of  the 
portal  veins,  either  from  compression  or  inflammation.  Tumors  of 
the  abdomen  are  often  attended  by  ascites,  particularly  solid  tumors 
of  the  ovary.     The  general  causes  of  ascites  are  the  causes  of  dropsy. 

Symptoms.  The  abdomen  is  eularged,  the  enlargement  being  uni- 
form. The  skin  is  tense  if  the  effusion  is  large,  and  linece  albicantes 
may  be  seen.  The  navel  may  project.  If  the  ascites  is  due  to  liver 
disease  or  disease  of  the  portal  vein,  the  superficial  veins  enlarge, 
although  the  enlargement  is  sometimes  seen  when  any  effusion  con- 
tinues a  long  period  of  time.  On  palpation  fluctuation  can  usually 
be  detected.  Care  must  be  taken  not  to  confound  the  wave  of  the 
abdominal  walls,  produced  by  percussion,  with  the  wave  of  the  fluid 
underneath;  the  former  must  be  cut  off  by  the  hand  of  an  assistant 
placed  vertically  in  the  median  line.  The  left  hand  should  be  applied 
firmly  against  one  side  of  the  abdomen,  while  with  the  right  percussion 
or  tapping  is  gently  performed  at  the  opposite  point.  The  points 
selected  should  be  at  about  the  level  of  the  fluid.  At  first  the  hand 
should  be  placed  on  the  flank,  and  if  the  fluctuation  is  not  revealed, 
then  with  each  successive  percussion  it  should  be  brought  forward 
toward  the  median  line.  Sometimes  light  percussion  will  yield  the 
sign,  at  others  more  firm  percussion  must  be  employed.  The  faintest 
tap  may  be  sufficient.  In  order  to  ascertain  the  position  of  solid 
organs  in  ascites,  dipping  is  employed  by  suddenly  pressing  the  tips  of 
the  fingers  over  the  organ  sought  for.  The  fluid  is  thus  displaced  and 
the  edge  or  surface  of  the  organ  readily  felt. 

Percussion.  When  the  abdomen  is  percussed  in  the  usual  manner 
there  is  dulness  over  the  fluid.  As  the  fluid  gravitates  to  dependent 
portions  the  dulness  is  found  in  these  portions.  When  the  patient  is 
lying  down,  it  is  in  the  flanks,  and  may  extend  around  the  lower  por- 
tion of  the  abdomen.  If  the  patient  stands  up,  the  dulness  may  reach 
to  the  umbilicus  in  the  median  line  and  to  the  same  level  in  the  mid- 
clavicular line.  The  subjective  symptoms  are  those  due  to  the  cause  of 
the  ascites  and  to  mechanical  pressure.  In  ascites  it  is  important  to 
ascertain  the  nature  of  the  fluid.  This  can  only  be  done  by  aspiration. 
If  the  fluid  is  serous,  it  has  the  characteristics  belonging  to  that  fluid. 
Hemorrhagic  effusions  usually  occur  in  cancer  and  tubcrculo-is, 
although  both  of  these  diseases  may  occUr  with  clear  serum.  In  rup- 
tured tubal  pregnancy,  the  effusion  is  hemorrhagic.  In  rare  cases  a 
chylous,  milky  fluid  is  found  in  disease  of  the  lymphatics.     In  one 


618  SPECIAL  DIAGNOSIS. 

iu stance  this  occurred  from  perforation  of  the  thoracic  duct.  Chylous 
ascites  may,  however,  be  due  to  an  excessive  milk-diet.  In  other 
instances  it  is  due  to  filaria.  The  patient  on  a  milk-diet  is  often  lip- 
amiic,  in  consequence  of  which  effusions  are  made  turbid. 

Ascites  must  be  distinguished  from  enlargement  of  the  abdomen  due 
to  ovarian  tumor,  enlargement  due  to  pregnancy,  and  enlargement  due 
to  an  overdistended  bladder.  In  ovarian  tumor  the  development  at 
first  takes  place  to  the  right  or  left  of  the  median  line.  If  enlarged, 
the  signs  of  it  may  be  in  the  central  region  of  the  abdomen.  The 
flanks,  however,  are  always  tympanitic  on  percussion.  On  vaginal 
examination  the  local  disease  may  be  ascertained.  A  distended  blad- 
der should  always  be  thought  of,  aud  catheterization  performed  in 
doubtful  cases.  Cysts  of  the  pancreas  may  be  mistaken  for  ascites, 
and  large  hydatid  cysts  connected  with  the  liver  may  simulate  an 
accumulation  of  fluid  in  the  peritoneal  cavity.  The  history  and  the 
appearance  of  the  fluid  on  aspiration  point  to  the  diagnosis. 

Cancer  of  the  Peritoneum. 

It  usually  occurs  in  the  aged,  and  follows  cancer  in  other  organs,  as 
the  stomach,  liver,  or  uterus.  Occasionally  it  is  primary.  The  omen- 
tum is  indurated  and  forms  a  mass  which  lies  transversely  across  the 
abdomen  in  the  upper  zone.  Ascites  usually  develops,  and  the  exu- 
dation is  bloody.  The  disease  occurs  more  frequently  in  women  than 
iu  men.  With  the  development  of  ascites  there  is  emaciation.  The 
surface  of  the  indurated  omentum  is  irregular.  It  may  be  painful  on 
pressure.  The  same  character  of  tumor  is  seen  in  tuberculous  peri- 
tonitis, and  I  have  seen  several  such  tumors  in  the  aged  without  appar- 
ent cause,  unless  it  were  from  proliferative  peritonitis  (see  Tumor). 
Progressive  emaciation,  chronic  ascites  without  cause,  and  a  localized 
tumor  without  the  occurrence  of  fever  point  to  the  probable  nature  of 
the  case.  Sometimes  pain  is  the  most  pronounced  symptom.  If  these 
symptoms  are  present  without  symptoms  of  disease  in  other  organs, 
as  the  stomach,  rectum,  or  uterus,  there  is  probably  cancer  of  the 
peritoneum. 

Retroperitoneal  sarcoma,  or  Lobstein's  cancer,  is  central,  deep-seated, 
and  fixed.  It  is  accompanied  by  the  general  symptoms  of  cancer  and 
by  ascites.  The  growth  is  very  large.  It  can  be  detected  above  the 
sacrum  by  rectal  examination.  The  intestines  are  in  front  of  the 
growth,  causing  an  unusual  sensation  to  the  hand,  as  in  Burrow's 
case,  like  a  hydatid  fremitus.  Lockwood' s  cases  were  believed  to  be 
solid  ovarian  tumors. 

Tuberculosis  of  the"  Peritoneum. 

The  tuberculous  process  in  the  peritoneum  may  be  either  acute  or 
chronic.  In  some  instances  it  may  continue  without  any  symptoms, 
either  local  or  general.  Acute  tuberculous  peritonitis  may  exactly 
simulate  suppurative  peritonitis,  save  that  the  course  is  more  prolonged 
and  the  fluctuations  of  temperature  less  pronounced.    In  other  respects 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     619 

it  cannot  be  distinguished  from  acute  general  peritonitis,  save  by  the 
absence  of  the  causes  of  the  latter.  A  history  of  liability  to  tubercu- 
lous infection,  or  the  presence  of  tuberculosis  in  some  other  portion  of 
the  body,  may  be  of  service  in  determining  the  nature  of  the  case. 
This  is  sometimes  impossible.  Usually  there  occurs  in  a  short  time 
associate  tuberculosis  of  other  serous  membranes,  so  that  tuberculous 
pleurisy  or  tuberculous  pericarditis  will  supervene,  an  associate  process 
which  does  not  take  place  in  ordinary  peritonitis.  At  the  same  time 
there  is  diarrhoea  in  most  cases — at  least  this  has  been  present  in  the 
few  instances  in  which  I  have  seen  this  form  of  tuberculosis.  Henry 
has  called  renewed  attention  to  the  occurrence  of  inflammation  about 
the  navel  as  a  sign  of  tuberculous  peritonitis.  He  believes  the  peri- 
umbilical erythema  is  pathognomonic  of  the  affection. 

Acute  tuberculosis  of  the  peritoneum  may  precisely  simulate  acute 
appendicitis  in,  first,  the  local  symptoms  and  signs;  and,  second,  the 
subsequent  infection  of  the  peritoneum.  In  acute  tuberculous  appen- 
dicitis, however,  the  signs  of  a  tumor  are  not  so  marked  as  in  true 
appendicitis.  Nevertheless,  in  one  instance,  Keen  operated  upon  a 
patient  of  mine,  a  healthy  laborer  in  a  rolling-mill,  who  had  the  clas- 
sical symptoms  of  appendicitis.  At  the  operation  the  appendix  was 
found  to  be  perforated  and  hanging  in  a  local  abscess.  A  faecal  fistula 
ensued  which  did  not  heal,  and  within  two  months  the  patient  died  of 
general  tuberculosis.  The  appendix  was  the  seat  of  primary  tubercu- 
lous ulceration.  In  a  second  instance  the  appendicitis  arose  in  the 
course  of  tuberculosis. 

In  a  third  instance  the  patient,  aged  forty-five  years,  was  admitted 
to  my  wards  in  the  Philadelphia  Hospital,  with  high  fever  and  pain 
in  the  abdomen,  at  first  more  pronounced  along  the  margin  of  the  liver. 
By  the  end  of  twenty- four  hours  it  became  more  decided  in  the  right 
lower  quadrant  of  the  abdomen  ;  tenderness  at  McBurney's  point  was 
distinct,  the  area  was  enlarged,  dull  on  percussion,  the  surface  slightly 
cedematous.  Fluctuation  could  not  be  detected.  Extension  of  the  leg 
was  painful.  Rapid  general  peritonitis  ensued,  during  which  the  sur- 
geon saw  him,  but  declined  to  operate  until  the  subsidence  of  the 
attack.  When  the  attack  subsided  the  local  signs  of  tumor  were  not 
present.  The  fever  persisted  irregularly  for  a  short  time,  indeed  the 
more  acute  peritoneal  symptoms  subsided ;  then  the  right  pleura  be- 
came infected,  and  cough  ensued  with  expectoration  of  muco-purulent 
fluid.  It  did  not  contain  tubercle  bacilli,  however.  Subsequently  the 
left  pleura  and  the  pericardium  became  involved.  During  the  entire 
course  of  the  disease  there  were  diarrhoea,  most  pronounced  sweats, 
rapid  emaciation,  and  exhaustion.  At  the  end  of  five  weeks  death 
took  place,  and  at  the  autopsy  general  serous  tuberculosis  was  found 
to  be  present. 

While  in  a  number  of  instances  the  symptoms  are  acute  and  alarm- 
ing, in  the  larger  proportion  of  cases  the  process  is  more  chronic,  and 
i-  attended  by  characteristic  local  and  general  symptoms.  In  the  pro- 
longed and  moderate  cases  there  may  be  continued  fever  of  moderate 
degree,  or  it  may  be  remitting  in  type.  In  old  people  the  temperature 
is  frequently  subnormal  (see  Fig.  113).     With  the  fever  there  is  more 


620 


SPECIAL  DIAGNOSIS. 


or  less  rapid  emaciation.  The  sweating  is  profuse  and  characteristic. 
In  more  severe  cases  the  fever  is  high  but  irregular  in  type,  approach- 
ing more  the  remittent  form.  The  general  symptoms  very  much 
resemble  typhoid  fever.      Indeed,  symptoms  of  the  typhoid  state  may 


ensue. 


Fig.  113. 


IOI- 
IOO— 

V      r 

ft 

-- 

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Tuberculous  peritonitis.    Subnormal  temperature. 

The  Local  Symptoms.  Four  classes  are  seen  :  (l)  Abdominal  enlarge- 
ment with  effusion;  (2)  enlargement  with  tumors;  (3)  combination  of 
the  two;  (4)  enlargement  without  marked  evidence  of  fluid  or  tumor 
in  the  abdomen.  In  this  form  and  in  the  forms  in  which  tumors  are 
present  the  abdomen  subsequently  may  undergo  retraction. 

1.  Enlargement  with  Effusion.  The  local  symptoms  and  physical 
signs  are  those  of  ascites.  The  abdomen  is  never  so  distended,  how- 
ever, as  in  the  ascites  of  cirrhosis  of  the  liver.  Often  the  fluid  is  not 
movable  on  account  of  adhesions  which  may  be  distinctly  localized  in 
the  right  or  left  quadrant  of  the  abdomen,  in  which  situations  fulness 
and  fluctuation  may  be  readily  detected. 

2.  Tuberculosis  with  Tumors.  Tlie  tumors  are  usually  in  the  upper 
zone  of  the  abdomen,  and  may  be  localized  to  either  quadrant,  or 
extend  from  the  right  to  the  left.  They  are  usually  due  to  tubercu- 
losis of  the  omentum,  with  secondary  contraction.  In  some  instances 
a  hard,  indurated  tumor,  somewhat  tender  on  pressure,  may  extend 
across  the  abdomen  midway  between  the  xiphoid  cartilage  and  the 
umbilicus.  It  may  be  as  low  as  the  umbilicus,  and  vary  from  two  to 
four  inches  in  width.  It  may  be  continuous  with  the  liver-dulness. 
In  other  instances  more  distinctly  localized  masses  may  be  felt.  These 
may  be  to  the  right  or  to  the  left  of  the  umbilicus.  In  other  instances 
they  are  hard,  slightly  tender,  with  an  irregular  surface.  They  may 
be  movable  and  vary  with  the  change  of  position  of  the  patient.  I 
have  never  seen  tuberculous  masses  in  the  lower  quadrants.  In  chil- 
dren with  tabes  mesenterica  they  may  be  made  out  close  to  the  verte- 
bral column  in  the  median  line,  extending  to  the  brim  of  the  pelvis, 
although  at  the  lower  portion  they  are  not  so  distinct.  The  dulness 
over  the  tumors  is  varying,  depending  upon  the  relation  to  the  bowels 


DISEASES  OF  STOMACH,  INTESTINES,  AND  PERITONEUM.     621 

and  the  degree  of  their  distention.      Instead  of  dulness,   a  modified 
tympany  may  be  observed,  or  muffled  resonance. 

3.  Canes  in  which  Effusion  and  Tumors  are  Present  at  the  Same  Time. 
These  present  symptoms  common  to  the  two  conditions,  although  the 
tumors  are  not  so  distinctly  denned. 

4.  Absence  of  Effusion  and  lumors.  When  effusion  and  tumors 
are  not  present  the  thickened  peritoneum  and  more  dense  intestinal 
walls  lead  to  a  modified  dulness  over  the  entire  abdomen.  When 
retraction  takes  place  the  resonance  is  of  a  woodeny  character,  the 
abdomen  is  more  or  less  tender,  and  ill-defined  indurations  may  be 
present.  The  term  carreau  is  applied  to  these  indurations.  In  not  a 
few  instances  the  local  physical  signs  may  apparently  be  due  to  inflam- 
mation of  the  liver  on  account  of  extensive  perihepatitis.  In  one  case 
of  a  child  the  local  signs  during  life  were  of  this  character,  and  the 
symptoms  were  simply  those  of  loss  of  appetite,  with  discomfort, 
weight,  and  fulness  below  the  sternum.  Both  the  right  and  left  lobes  of 
the  liver  were  covered  with  an  enormous  thickening  due  to  tuberculous 
inflammation.  Simple  plastic  peritonitis  occupied  the  lower  zone.  Apart 
from  the  general  symptoms  and  the  local  physical  signs  the  other  symp- 
toms are  not  distinct  save  those  due  to  tuberculosis  in  other  situations. 
The  appetite  is  usually  poor,  there  is  some  atonic  dyspepsia,  vomiting 
may  occur  at  regular  intervals  ;  the  bowels  may  be  constipated, 
although  in  my  experience  they  have  usually  been  relaxed.  The 
patient  becomes  anaemic,  the  skin  harsh  and  dry.  Emaciation  may 
progress  to  an  extreme  degree.  Eruptions  and  boils  may  break  out, 
some  oedema  of  the  ankles  may  occur.  Death  takes  place  from  exhaus- 
tion and  from  the  development  of  tuberculosis  in  other  localities. 

The  diagnosis  is  difficult.  Cases  belonging  to  the  first  and  fourth 
classes  above  mentioned  probably  present  the  greatest  difficulties. 
The  age  also  modifies  the  ability  to  make  a  diagnosis.  Peritoneal 
tumors  with  or  without  effusion  in  young  subjects  are  almost  always 
due  to  tuberculosis.  In  the  aged  they  must  be  distinguished  from 
carcinoma  or  chronic  peritonitis  from  other  causes.  The  association 
of  diarrhoea  with  the  symptoms  is  rather  against  carcinoma.  Sac- 
culated effusions  may  be  confounded  with  abdominal  tumors,  as  of  the 
ovary.  The  resemblance  is  more  pronounced  if  the  tubercles  develop 
primarily  in  the  tubes  or  uterus.  In  a  recent  case  the  autopsy  dis- 
closed a  large  caseating  ulcer  inside  of  the  uterus,  and  tuberculosis  of 
the  Fallopian  tubes  and  peritoneum.  The  right  tube  was  chiefly 
affected.  The  effusion  during  life  was  sacculated  in  the  right  quad- 
rant, was  not  movable  with  the  patient,  and  fluctuated  both  on  external 
palpation  and  with  bimanual  palpation  per  vaginam.  it  was  impossi- 
ble to  distinguish  it  except  that  there  was  dulness  instead  of  resonance 
in  the  flanks.  As  Osier  has  pointed  out,  the  association  with  salpin- 
gitis must  arouse  suspicion,  particularly  if  at  the  same  time  disease  is 
found  in  seme  other  organ  of  the  body,  as  the  apex  of  the  lungs  or 
the  pleura.  In  males  the  primary  lesion  is  often  in  the  testicles. 
The  history  of  the  case  and  the  development  of  the  disease  in  an  irreg- 
ular manner,  associated  with  gastro-intestinal  disturbance  rather  than 
disturbance  of  uterine  function,  are  points  in  favor  of  tuberculosis. 
Tympanites  is  of  frequent  occurrence. 


CHAPTEK   VI. 

DISEASES   OF   THE   LIVER,   SPLEEN,   AND   PANCREAS. 

The  symptoms  of  disease  of  the  liver  are  clue  to  the  morbid  process 
within  the  organ,  to  disturbance  of  the  functions  of  the  hepatic  cells, 
or  to  obstruction  of  the  channels  for  the  flow  of  blood  and  bile.  As 
these  lie  beyond  the  glandular  structure  of  the  liver  they  may  be 
affected  by  disease  outside  of  the  liver.  Hepatic  symptoms  may, 
therefore,  be  due  to  disease  outside  of  the  liver. 

The  morbid  process  may,  in  time,  cause  alterations  in  function, 
obstruction  of  channels,  or  physical  alterations  in  the  size  and  shape 
of  the  liver.  The  latter  may  also  be  due  to  disease  outside  of  the 
liver. 

Symptoms  due  to  the  Morbid  Process.  The  morbid  processes 
are  chiefly  congestion  of  the  liver,  abscess,  cancer  of  the  liver,  and  the 
degenerations. 

In  congestion  of  the  liver  the  symptoms  are  (1)  the  symptoms  of 
the  cause,  (2)  enlargement  of  the  organ  from  the  increased  amount  of 
blood,  (3)  functional  disturbance  from  the  same  cause.  The  conges- 
tion is  not  limited  to  the  vessels  in  relation  with  the  liver-cells,  but 
involves  the  vessels  of  the  mucous  membrane  also,  hence  the  latter  are 
swollen,  obstructing  the  ducts  and  producing  jaundice  in  moderate 
degree.  In  abscess  of  the  liver  we  have  the  symptoms  of  suppuration 
and  changes  in  the  shape  of  the  organ.  No  modifications  of  its  func- 
tion are  observed,  and  obstruction  of  the  channels  rarely  takes  place. 
In  cancer  of  the  liver  the  symptoms  are  those  of  malignant  disease  in 
general,  to  which  are  added  symptoms  due  to  change  in  the  size  of  the 
liver,  and,  more  frequently  than  in  abscess,  symptoms  due  to  obstruc- 
tion of  the  channels.  The  degenerations  are  so  frequently  secondary 
to  and  masked  by  the  symptoms  of  their  primary  cause  that,  save  in 
regard  to  change  of  size,  there  are  no  hepatic  symptoms  worth  men- 
tioning. 

Symptoms  due  to  Functional  Disturbance  of  the  Liver. 
The  functions  of  the  liver  are,  first,  to  secrete  bile;  second,  to  destroy 
the  haemoglobin  of  the  blood  ;  third,  to  destroy  or  neutralize  poisons 
entering  the  portal  circulation  through  the  intestinal  tract,  or  to  modify 
their  character.  Bile  is  not  secreted  when  the  liver-cells  are  destroyed, 
as  in  acute  yellow  atrophy.  This  condition  gives  rise  to  jaundice,  hem- 
orrhages, and  grave  cerebral  symptoms ;  the  liver  does  not  destroy  the 
normal  amount  of  haemoglobin.  On  the  other  hand,  haemoglobin  may 
be  so  much  in  excess  that  the  liver  cannot  destroy  it;  jaundice  then 
results  (see  Hseinatogenous  Jaundice).  Functional  disturbances  of  the 
liver  are  seen  clinically  when  products  of  digestion  are  not  completely 
destroyed  by  the  liver  and  are  permitted  to  enter  the  circulation.     Thus 


DISEASES  OF  THE  LIVES,  SPLEEN,  AND  PANCREAS.      623 

we  have,  on  the  one  hand,  glycosuria;  on  the  other,  lithsemia  or  other 
toxic  states. 

Lithsemia  is  the  more  common  condition  and  is  believed  to  be  due 
to  liver-disturbance.  There  is  an  excess  of  uric  acid  and  urates,  or 
of  other  metabolic  compounds  in  the  blood.  The  symptoms  that  are 
produced  are,  first,  symptoms  of  excess  of  lithic  acid  in  the  system; 
second,  the  effects  of  the  lithic  acid  upon  the  nervous  system.  Lith- 
semia may  be  acute  or  chronic. 

Acute  Lith.emia  ;  Biliousness.  When  acute  the  local  disturb- 
ances are  :  furred  tongue,  a  bitter  taste  in  the  mouth,  anorexia,  nausea, 
disgust  at  the  sight  of  food,  with  possible  morning  vomiting.  There 
is  some  tenderness  in  the  upper  mid-abdomen,  and,  after  eating,  weight 
and  fulness  and  distress  in  that  region.  Flatulency  occurs.  Symp- 
toms of  intestinal  dyspepsia  may  arise  secondarily.  Slight  fever  or 
feverishness  may  attend  the  attack.  The  skin  is  hot  and  burning  ;  or 
cold  perspirations  may  break  out  at  irregular  times,  alternating  with 
flashes  of  heat.  The  bowels  are  constipated,  the  stools  are  clay-colored. 
The  symptoms  may  be  attended  by  slight  obstruction  to  the  ducts,  caus- 
ing a  moderate  degree  of  jaundice.  In  some  instances  the  liver  can 
be  made  out  slightly  enlarged.  The  urine  is  loaded  with  urates  and 
uric  acid.  It  is  scanty  and  high-colored,  and  there  may  be  painful 
micturition.  The  nervous  symptoms  are  usually  those  of  depression, 
as  headache,  some  dulness,  or  stupor  ;  the  patient  may  be  unusually 
drowsy.  The  headaches  may  be  the  most  prominent  feature  of  the 
attack.  They  are  frontal,  attended  by  slight  vertigo,  flashes  of  light 
or  spots  before  the  eyes,  and  ringing  in  the  ears. 

The  same  group  of  symptoms  is  seen  in  acute  gastro-duodenal  catarrh. 

Chronic  LrmiEMiA.  In  chronic  lithcemia  the  symptoms  are  vari- 
able and  are  characterized  by  disturbance  of  function  in  nearly  all  the 
organs  of  the  body.  They  have  been  classically  described  by  Murch- 
ison,  Da  Costa,  and  others,  and  while  the  theory  is  fairly  satisfactory 
to  work  upon  for  lines  of  treatment,  the  same  group  of  symptoms  may 
be  met  with  in  forms  of  chronic  indigestion,  particularly  the  forms  in 
which  there  is  inability  to  digest  sugars  and  starches.  By  some  the 
symptoms  are  attributed  to  chronic  intestinal  catarrh. 

Symptoms.  The  patients  are  in  ill  health  and  subject  to  chronic 
indigestion.  They  may  be  under  weight  or  corpulent.  The  skin  is 
harsh  and  dry,  its  nutrition  poor.  It  is  subject  to  erythema;  or  local 
inflammations,  as  eczema,  may  arise.  Irregular  sweats  occur,  alternat- 
ing with  intervals  when  the  skin  is  hot  and  dry.  The  extremities  are 
cold  and  clammy,  and  tingling  and  numbness  are  often  complained  of. 

Gastro-intestinal  Symptoms.  The  symptoms  are  those  of  chronic 
indigestion.  There  is  constantly  a  furred  tongue  with  local  dyspeptic 
symptoms.  The  bowels  are  irregular  or  constipated  ;  sometimes  mucus 
is  passed.  Flatulency  is  excessive,  both  gastric  and  intestinal.  An 
icteric  tinge  may  be  seen  on  account  of  a  slight  local  catarrh  of  the 
ducts,  or  of  hepatic  congestion.  It  recurs  at  frequent  periods,  while 
a  sallow  complexion  is  more  or  less  constant. 

Respiratory  Symptoms,  The  patient  is  liable  to  attacks  of  catarrh 
of  the  upper  air-passages,  and  especially  to  pharyngitis.     In  lithsemic 


g24  SPECIAL  DIAGNOSIS. 

states  tonsillitis  is  not  uncommon.  Chronic  pharyngitis  is  present.  On 
the  other  hand,  some  persons,  particularly  those  over  fifty  years,  have 
chronic  bronchitis,  and  attacks  of  asthma  are  common.  The  bronchitis 
cannot  be  distinguished  from  that  due  to  other  causes,  except  by  the 
fact  that  the  subject  is  lithseinic.  Emphysema  of  the  lungs  develops 
on  account  of  bronchitis  and  tissue-degeneration. 

Cardiac  Symptoms.  Palpitation  is  a  constant  accompaniment  of 
many  forms  of  litharnia;  in  others  there  may  be  unduly  rapid  action 
of  the  heart,  or,  during  exacerbations,  slowness  of  the  heart's  action. 
In  the  later  stages  pseudo  angina  pectoris  is  of  common  occurrence. 
In  the  earlier  stages  pain  about  the  heart  or  in  the  left  side  is  fre- 
quently complained  of. 

Nervous  Symjrtoms.  Constant  headache,  worse  in  the  morning, 
relieved  toward  the  end  of  the  day.  Some  vertigo  may  be  present. 
There  are  depression  of  spirits  and  inaptitude  for  mental  exertion.  The 
memory  is  dull,  the  faculties  blunted.  The  patient  is  subject  to  back- 
ache, chiefly  in  the  loins.  Pain  in  the  right  shoulder  is  of  frequent 
occurrence.  In  addition,  pains  along  the  course  of  the  nerves  (neu- 
ritis), and  myalgias,  are  of  common  occurrence.  The  nerve-trunks 
may  be  tender.  There  is  tenderness  in  the  sheaths  of  the  muscles,  or 
at  the  insertions  of  fasciae  and  tendons.  Peripheral  nerve-sensations 
are  common.  Numbness  and  tingling  are  frequently  complained  of. 
Paresthesias  of  all  forms,  variously  distributed,  are  a  source  of  annoy- 
ance. Local  sensations  of  heat  or  burning  alternate  with  areas  of 
coldness.  Tingling,  pricking  of  needles,  and  other  forms  of  paresthesia 
occur. 

The  Urine  The  urine  is  high-colored  and  contains  an  abundance 
of  uric  acid  and  urates.  The  amount  is  scanty,  the  specific  gravity 
high.  There  may  be  albumin,  small  in  amount,  depending  upon  the 
irritation  of  the  urates  in  their  passage  through  the  kidneys.  Cylin- 
droids  are  present;  casts  are  not  common,  although  at  times,  when  the 
uric  acid  is  passed  in  excess,  there  may  be  a  secondary  nephritis,  with 
albumin,  blood,  and  casts.  As  an  ultimate  result  of  such  condition 
we  may  have  gallstones,  or  calculi  in  the  kidneys  and  bladder.  Lith- 
semic  patients  are  subject  to  attacks  of  hepatic  or  renal  colic. 

As  part  of  the  same  process  or  an  accompaniment  we  may  have  gout 
or  rheumatism.  Acute  inflammatory  rheumatism  (rheumatic  fever) 
does  not  belong  to  this  category,  but  muscular  rheumatism,  subacute 
inflammation  of  the  joints  with  moderate  fever,  true  gout,  and  gout 
with  its  modifications  when  seated  in  the  various  joints,  are  the  ultimate 
outcome  of  this  process  in  the  patient.  Attacks  of  gout  may  occur 
in  a  patient  who  has  not  shown  any  symptoms  of  lithtemia,  but  those 
who  have  symptoms  of  lithsemia  arernore  susceptible  to  causes  which 
produce  attacks  of  gout.  The  gouty  and  rheumatic  manifestations  are 
due  to  the  deposition  of  uric  acid  and  urates  in  tissues  which  are  not 
highly  vitalized,  and  in  which,  therefore,  the  circulation  is  sluggish. 

Lithremia  later  assumes  the  gouty  aspect.  Tophi  are  seen  in  the 
situations  natural  to  them.  The  appearance  of  the  face  is  characteristic, 
with  capillary  congestions  and  stases.  The  patients  usually  become 
more  or  less  obese  and  are  subject  to  attacks  of  glycosuria.      Early  in 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       625 

their  life  degenerations  of  vessels  take  place.  The  kidneys  are  always 
under  an  excessive  strain.  A  good  deal  of  material  is  not  discharged; 
its  effects  upon  peripheral  vessels  are  such  as  to  cause  heightened  ten- 
sion, therefore  undue  vasomotor  congestion  of  the  vessels  takes  place, 
leading  to  low-grade  inflammations,  with  the  development  of  atheroma. 
For  the  same  reason  chronic  interstitial  nephritis  is  set  up,  and,  because 
of  heightened  strain  in  the  vascular  system,  chronic  sclerotic  valvulitis. 

Functional  symptoms  from  disorder  of  the  liver  are  otherwise  not 
marked,  unless  we  include  a  group  of  cases  in  which  sudden  coma  and 
convulsions  take  place,  presumably  because  material  has  been  absorbed 
from  the  gastro-mtestinal  tract  and  enters  the  general  circulation 
through  the  temporary  cessation  of  the  function  of  the  liver,  the  office 
of  which  is  to  destroy  the  material.  Such  symptoms  may  arise  in 
organic  disease  of  the  liver,  as  cirrhosis. 

Symptoms  due  to  Obstruction  of  the  Channels.  (1)  Obstruc- 
tion of  the  bile-ducts,  either  from  disease  or  external  pressure,  causes 
jaundice,  pain,  and  fever.  The  three  symptoms  may  occur  singly 
or  combined.  Jaundice  may  occur  alone  in  obstruction  by  gallstones  ; 
pain  may  occur  with  it,  or  jaundice,  pain,  and  fever  may  occur  to- 
gether ;  rarely,  pain  or  fever  may  be  present  alone.  Each  symptom 
will  be  described  later.  (2)  Obstruction  of  the  blood-channels  causes 
hyperaemias  of  the  liver  which  may  be  active  or  passive,  or  portal 
congestions.  The  symptoms  of  each  will  be  discussed;  suffice  it  to  say 
that  here  again  the  symptoms  are  modified  by  the  process.  Thus,  in 
portal  obstruction  from  pressure  the  symptoms  are  quite  different 
from  the  symptoms  of  portal  obstruction  due  to  suppurative  inflam- 
mation of  the  vein. 

Hyperemia  of  the  Liver.  In  the  hypercemias  the  liver  is  enlarged. 
If  the  hyperemia  is  active,  painful  distention  may  be  complained  of, 
and  the  organ  may  be  the  seat  of  some  tenderness.  There  may  be,  in 
addition,  weight  and  fulness  in  the  liver-region.  Active  hypersemia 
may  follow  a  chill  or  suppression  of  the  menses,  but  more  frequently 
occurs  after  indiscretions  of  diet,  the  free  use  of  alcohol,  or  stimulat- 
ing food,  followed  by  an  attack  of  acute  gastro-intestinal  catarrh.  It 
is  more  common  in  the  tropics,  and  is  due  in  that  climate  to  suppres- 
sion of  the  perspiration.  It  is  recognized  by  the  occurrence  of  symp- 
toms of  acute  gastritis  with  enlargement,  pain,  and  tenderness  of  the 
liver.  Slight  jaundice  may  attend  the  attack.  Passive  congestion  is 
also  attended  by  enlargement  of  the  liver.  The  enlargement  may 
cause  a  sense  of  weight  or  fulness,  but  pain  is  not  complained  of.  The 
organ  is  not  tender,  the  edges  are  smooth  and  indurated.  The  liver 
may  pulsate.  This  is  detected  by  placing  the  hand  over  the  surface 
of  the  liver,  when,  with  each  impulse  of  the  heart,  the  organ  can  be 
felt  to  expand.  The  symptoms  of  the  cause  of  the  passive  congestion 
combine  with  those  just  enumerated  as  due  to  enlargement  of  the  organ. 
In  addition  we  have  symptoms  due  to  obstruction  of  the  flnw  of  blood 
in  the  portal  circuit.  Passive  congestion  occurs  in  organic  heart  disease 
alter  compensation  has  failed  and  the  right  heart  is  dilated.  The  organ 
rapidly  becomes  congested  because  of  its  close  proximity  to  this  cham- 
ber.    In  emphysema  of  the  lungs,  in  fibroid  phthisis,  in  intrathoracic 

40 


626  SPECIAL  DIAGNOSIS. 

tumors  pressing  upon  the  vena  cava,  mechanical  congestion  takes  place. 
The  recognition  of  passive  congestion  is  not  difficult.  The  symptoms 
due  to  enlargement  (see  Objective  Symptoms)  and  the  symptoms  due 
to  portal  obstruction  point  to  the  true  nature  of  the  morbid  process. 

The  Symptoms  of  Portal  Obstruction.  These  arise  from  disease  of 
the  portal  vein,  or  from  occlusion  of  the  branches  obstructing  the  flow 
of  blood. 

The  diseases  of  the  portal  vein  are  thrombosis,  adhesive  and  suppu- 
rative inflammation.  (1)  Thrombosis  of  the  portal  vein  attends  cirrhosis 
of  the  liver,  or  may  occur  secondarily  to  pressure  upon  the  vein  by  a 
tumor  within  the  abdomen.  Disease  of  the  pancreas  was  the  cause 
of  the  pressure  in  a  patient  under  my  observation.  As  a  result  of 
thrombosis  adhesive  inflammation  of  the  vein  takes  place,  and  a  col- 
lateral circulation  is  established  to  replace  its  function. 

The  symptoms  in  disease  of  the  trunk  of  the  portal  vein,  which  leads 
to  obstruction  of  this  character,  are  the  same  as  in  obstruction  of  the 
terminal  branches,  and  are  known  as  the  symptoms  of  portal  conges- 
tion (see  below).  In  one  respect  only  do  they  differ.  While  we  have 
ascites  in  both,  in  thrombosis  of  the  portal  vein  it  occurs  suddenly,  and 
is  characterized  by  rapid  recurrence  after  tapping. 

(2)  Suppurative  inflammation  of  the  portal  vein  is  attended  by  symp- 
toms resembling  pyaemia;  the  condition  is  called  portal  pyaemia.  The 
inflammation  is  secondary  and  depends  upon  inflammation  in  the  portal 
area.  It  follows  appendicitis  with  peritonitis,  ulceration  of  the  hemor- 
rhoidal veins,  inflammation  of  the  veins  from  ulceration  or  suppuration 
anywhere  in  the  gastro-intestinal  tract.  The  enlarged  portal  vein 
being  the  seat  of  suppuration,  it  naturally  follows  that  pus  is  carried 
into  the  liver.  In  consequence  thereof,  multiple  hepatic  abscesses  arise. 
Three  pathological  affections  are  therefore  seen  :  (1)  Suppuration  in  the 
portal  area ;  (2)  inflammation  of  the  vein  ;  (3)  multiple  abscesses  of 
the  liver  (for  the  symptoms  of  which  see  Abscess). 

Symptoms  of  obstruction,  from  occlusion  or  overfilling  of  the  branches 
of  the  liver.  This  condition  occurs  in  passive  congestion,  and  most 
typically  in  cirrhosis  of  the  liver.  The  circulation  of  the  liver  is 
interfered  with,  and  the  blood  is  thrown  back  into  the  portal  vein, 
overfilling  the  other  end  of  the  portal  circuit.  As  a  result  we  have 
(1)  congestion  of  the  mucous  membrane  of  the  stomach  and  bowels, 
with  the  symptoms  of  gastro-intestinal  catarrh  ;  (2)  dilatation  of  the 
veins,  chiefly  the  hemorrhoidal,  giving  rise  to  hemorrhoids ;  (3)  the 
occurrence  of  ascites  ;  (4)  the  occurrence  of  hemorrhages.  Hemor- 
rhages due  to  disease  of  the  liver  may  occur  in  any  part  of  the  gastro- 
intestinal tract.  Hsematemesis  and  intestinal  hemorrhage  are  seen. 
The  vomiting  of  blood  may  be  in  small  amounts,  associated  only  with 
the  discharge  of  mucus.  In  some  cases  large  hemorrhages  take  place 
either  from  the  mucous  membrane  of  the  stomach  or  from  the  veins 
about  the  oesophagus,  which  often  become  varicosed  in  cirrhosis. 
Hemorrhages  from  the  intestine  may  be  from  enlarged  hemorrhoidal 
veins,  from  an  intestinal  ulcer,  or  from  the  mucous  membrane  of  the 
intestinal  tract.  (5)  Enlargement  of  the  spleen.  (6)  The  changes  due 
to  the  establishment  of  the  collateral  circulation.      If  complete  collat- 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       627 

eral  circulation  is  established,  the  above  symptoms  may  not  ensue. 
The  collateral  circulation  may  be  established  through  deep-seated  or 
through  superficial  veins.  If  the  latter,  the  external  veins  of  the 
abdomeu  are  enlarged.  The  epigastric  and  mammary  veins  become 
prominent.  At  times  the  veins  about  the  umbilicus  distend,  and  they 
may  become  so  enlarged  and  prominent  as  to  form  a  swelling  to  which 
the  term  caput  Medusce  has  been  applied.  The  venules  along  the  line 
of  attachment  of  the  diaphragm  in  the  lower  thoracic  zone  are  over- 
distended.     They  may  be  the  seat  of  pulsation.1 

The  enlarged  terminal  branches  of  the  portal  vein  press  upon  contig- 
uous structures  and  interfere  with  the  circulation  of  blood  in  the  major 
vascular  system  of  the  liver,  inviting  catarrh  of  the  terminal  ducts, 
which  leads  to  their  obstruction  and  hence  to  jaundice.  This  is  seen 
quite  frequently  in  passive  congestion  of  the  liver,  rarely  in  cirrhosis. 

Symptoms  due  to  the  Changes  in  Shape  and  Size.  The 
liver  maybe  enlarged,  contracted,  or  irregular.  (See  Objective  Symp- 
toms.) When  the  liver  is  contracted  symptoms  of  portal  obstruction 
usually  occur;  when  enlarged  they  occur  sometimes. 

The  Data  Obtained  by  Inquiry. 

A  knowledge  of  serological  factors  is  of  aid  in  the  diagnosis  of 
hepatic  affections.  In  disease  of  the  liver  more  than  in  any  other 
organ  of  the  body  we  find  the  affection  secondary  to  disease  elsewhere. 
Moreover,  diseases  of  the  liver  are  almost  always  associated  with  definite 
causes,  the  presence  or  absence  of  which  is  of  great  diagnostic  signifi- 
cance. In  the  study  of  hepatic  disease  we  consider,  therefore,  among 
setiological  factors,  the  age,  the  sex,  the  habits  of  life,  the  climate, 
and  the  presence  or  absence  of  disease  in  other  portions  of  the  body. 
Primary  liver  disease  is  comparatively  rare.  Secondary  liver  disease, 
on  the  other  hand,  is  of  common  occurrence.  There  are  but  few  gen- 
eral diseases  or  states  of  the  system  that  do  not  in  some  way  influence 
the  liver.  The  above  remarks  refer  to  organic  disease.  Functional 
disorders  of  the  liver,  as  previously  remarked,  are  so  difficult  to  separate 
from  functional  disorders  of  the  stomach  and  intestines  that,  practi- 
cally, from  an  setiological  and  clinical  standpoint,  they  go  hand-in-hand. 

The  Age.  Diseases  of  the  liver  usually  occur  late  in  life  because  the 
causes  upon  which  they  depend  are  operative  only  at  that  period.  In 
a  case,  therefore,  of  ill  health  in  a  young  subject,  when  the  cause  can- 
not well  be  determined,  the  liver  is  not  so  likely  to  be  the  seat  of  disease 
as  in  older  subjects.  Late  in  life  we  have  gallstones  with  their  multiple 
consequences,  cirrhosis  and  cancer.  We  may,  however,  have  the  con- 
gestions and  the  degenerations  in  early  life,  although  not  so  frequently. 
The  Sex.  The  sex  is  not  of  much  significance  from  a  diagnostic 
standpoint.  Cancer  may  be  more  frequent  in  the  female  sex,  because 
cancer  of  the  uterus  and  other  organs  is  more  common.  Cancer  of  the 
biliary  passages  is  more  frequent  in  ferr.  ales,  because  in  that  sex  gall- 
stones, which  are  setiological  factors  in  cancer,  are  more  common. 
Cirrhosis,  also,  is  said  to  be  relatively  more  frequent  in  females. 

1  Musser:  Trans.  Phil.  Path.  Soc,  vol.  xi.  p.  20. 


628  SPECIAL  DIAGNOSIS. 

The  Habits.  It  is  always  necessary  to  inquire  into  the  habits  before 
making  a  diagnosis.  Alcoholism  points  to  cirrhosis;  the  excessive 
use  of  stimulating  foods  to  hyperemia;  sedentary  habits  and  the  use 
of  starches  and  fats  to  gallstones.  The  occupation  has  but  little  influ- 
ence in  the  development  of  hepatic  disease.  With  regard  to  the 
climate,  it  may  be  said  that  in  tropical  countries  hypersemias  and  ab- 
scess of  the  liver  are  more  frequent. 

Previous  Disease.  It  is  absolutely  essential  to  inquire  into  this  to 
establish  a  diagnosis.  The  occurrence  of  heart  disease  or  obstructive 
lung  disease  points  to  a  congestion;  infectious  diseases  to  cirrhosis  when 
that  is  not  otherwise  accounted  for;  dysentery  to  abscess  ;  ulceration 
or  suppuration  in  the  portal  area  to  multiple  abscess;  syphilis  to  syph- 
ilitic disease;  tuberculosis,  suppurations,  bone  disease,  and  syphilis  to 
amyloid  disease;  pyaemia  to  multiple  abscesses;  tuberculosis  to  fatty 
liver. 

The  Subjective  Symptoms, 

The  subjective  symptoms  are  such  as  belong  to  functional  disorder 
of  the  liver,  conspicuous  among  which  are  gastro-mtestmal  symptoms 
and  toxaemia.      (See  Functional  Disturbance  and  Lithaemia.) 

Pain  is  a  frequent  symptom  of  liver  disease.  When  sudden  in 
onset,  acute,  and  increased  by  pressure  or  movement,  it  is  due  to  peri- 
hepatitis. Acute  paroxysmal  pain  below  the  ribs  or  in  the  epigastrium 
points  to  gallstones.  It  may  be  in  the  seventh  or  eighth  interspace. 
Pain  with  distention  occurs  in  congestion.  Stabbing  or  darting  pains 
belong  to  cancer.     The  pain  of  perihepatitis  may  attend  abscess. 

Pain  in  the  liver  must  not  be  confounded  with  pleurisy.  In  pneu- 
monia there  is  often  congestion  of  the  liver  and  perhaps  perihepatitis. 
The  associated  pain  has  been  taken  for  the  pain  of  hepatic  colic. 

The  Data  Obtained  by  Observation.     The  Objective  Symptoms. 

Topographical  Anatomy.  The  right  lobe  of  the  liver  is  applied 
to  the  concavity  formed  by  the  lower  lobe  of  the  right  lung,  being 
separated  from " it  by  the  diaphragm.  The  thin  lower  edge  of  the 
right  lung  overlaps  the  liver  at  its  upper  part,  but  the  greater  portion 
of  the  anterior  surface  of  the  right  lobe  of  the  liver  is  iu  contact  with 
the  ribs.  The  under  surface  of  the  liver  is  in  relation  with  the  stom- 
ach, transverse  colon,  duodenum,  right  kidney,  and  right  suprarenal 
capsule.  "  The  highest  part  of  its  convexity  on  the  right  side  is  about 
one  inch  below  the  nipple,  or  nearly  on  a  level  with  the  external  and 
inferior  angle  of  the  pectoralis  major.  Posteriorly  the  liver  comes  to 
the  surface  below  the  base  <  f  the  right  lung,  about  the  level  of  the 
tenth  dorsal  spine."      (Holden.) 

Roughly  speaking,  the  upper  border  of  the  liver  corresponds  with 
the  level  of  the  tendinous  centre  of  the  diaphragm — that  is,  the  level 
of  the  lower  end  of  the  sternum.  Thus,  a  needle  thrust  into  the  right 
side,  between  the  sixth  and  seventh  ribs,  would  traverse  the  lung,  and 
then  go  through  the  diaphragm  into  the  liver. 

The  attachments  of  the  liver  permit  of  a  certain  amount  of  move- 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       629 

ment.  Hence  the  liver  can  be  depressed  by  deep  inspiration,  emphy- 
sema of  the  lungs,  or  right  pleural  effusion.  If  the  patient  lie  upon 
his  left  side,  the  left  lobe  of  the  liver  rises  higher  and  the  right  extends 
lower,  and  vice  versa  if  the  patient  lie  upon  the  right  side,  the  liver 
turning  upon  the  suspensory  ligament  as  an  axis.      (Gerhardt.) 

Inspection.  Inspection  is  not  of  very  great  assistance  in  the  diag- 
nosis of  diseases  of  the  liver.  Frequently  there  is  a  swelling  in  the 
right  upper  cpiadrant,  which  may  or  may  not  be  produced  by  an  en- 
largement of  the  liver,  but  which  should  direct  attention  to  that  organ. 
The  lower  right  zone  of  the  thorax  may  also  be  distinctly  prominent. 
Such  a  swelling  may  be  observed  in  amyloid  disease,  hydatid  tumor, 
cancer,  abscess,  and,  less  frequently,  in  fatty  liver.  In  amyloid  and 
fatty  livers  the  projection  in  the  right  upper  quadrant,  which  may 
extend  to  the  left  beyond  the  median  line,  presents  a  smooth  surface, 
whereas  in  hydatid  tumor  there  is  frequently  a  rounded  projection  at 
some  part  of  the  prominent  area,  and,  in  cancer,  several  nodules  may 
be  large  enough  to  cause  slight  rounded  projections,  which  the  eye  is 
more  apt  to  detect  after  the  sense  of  touch  has  first  directed  attention 
to  their  presence. 

Enlargement  and  occasionally  pulsation  of  the  superficial  abdomi- 
nal veins  are  accompaniments  of  cirrhosis. 

Jaundice.  The  color  of  the  skin  and  of  the  mucous  membranes 
in  jaundice  has  been  described  (see  page  71).  In  addition  to  the  yel- 
low discoloration  jaundice  causes  a  number  of  symptoms  :  1.  Irrita- 
tions of  the  skin.  Pruritus  is  common  and  intense,  and  may  cause  great 
distress.  An  attack  of  jaundice  may  be  preceded  by  general  itching. 
It  occurs  in  all  forms,  but  is  more  marked  in  obstructive  jaundice  of 
long  duration.  Scratch-marks  are  seen  on  the  surface  of  the  skin,  and 
erythematous  eruptions  and  boils  frequently  occur.  Xanthelasma  is  a 
peculiar  affection  occurring  on  the  tongue,  on  the  skin  of  the  eyelids, 
and  about  the  ears  (see  page  125).  2.  Discoloration  of  the  secretions. 
All  the  secretions  of  the  body  are  changed  in  color,  as  previously 
described.  3.  Bile  absent  in  the  fasces.  The  stools  are  ashy  or  gray 
in  color.  4.  Sloivness  of  the  pulse.  The  heart's  action  falls  to  40  or 
30  to  the  minute,  or  even  lower.  5.  Hemorrhages.  In  the  later 
stages  of  all  forms  of  jaundice  hemorrhages  are  of  common  occurrence. 
In  acute  malignant  jaundice  they  are  seen  underneath  the  skin,  and 
come  from  the  mucous  membranes.  6.  Cerebral  symptoms,  irritability 
and  depression  of  spirits,  are  marked.  As  the  disease  advances  the 
mind  grows  sluggish;  the  patient  is  dull,  and  sleeping  most  of  the 
time.  Gradually  the  symptoms  of  the  typhoid  state  develop.  In  the 
acute  febrile  forms  coma  and  convulsions  follow  this  condition.  In 
the  affection  known  as  acute  yellow  atrophy  the  cerebral  symptoms  are 
marked,  and  occur  early.  Within  the  first  twenty-four  hours  there 
may  be  convulsions,  with  delirium  in  the  intervals,  and  subsequently 
coma. 

Causes.  Jaundice  is  (a)  hematogenous  or  non-obstructive  when  (1) 
the  function  of  the  liver-cells  has  been  suppressed,  as  in  acute  yellow 
atrophy  of  the  liver  ;  (2)  when  blood-destruction  is  in  excess  of  the 


630  SPECIAL  DIAGNOSIS. 

capacity  of  the  liver  to  remove  the  product  of  destruction — the  biliru- 
bin, as  in  certain  forms  of  malaria,  in  pernicious  anaemia,  in  certain 
fevers,  and  other  toxaemias.  (6)  Hepatogenous  when  there  is  obstruc- 
tion of  the  ducts.  The  obstruction  may  take  place  in  the  large  ducts 
or  in  the  smaller  terminal  ducts.  The  obstruction  is  due  (1)  in  the 
large  ducts,  to  disease  outside  of  the  ducts  ;  (2)  in  larger  and  smaller 
ducts,  to  disease  of  the  ducts  ;  or  (3)  in  all  sizes,  to  obstruction  within 
the  ducts. 

1.  From  the  pressure  upon  the  ducts,  of  tumors  of  the  stomach, 
kidney,  pancreas,  or  omentum;  of  tumors  of  the  liver  itself,  or  enlarged 
glands  in  the  fissure  of  the  liver;  of  accumulated  faeces  in  the  colon  ; 
of  abdominal  aneurism  ;  and,  in  rare  instances,  of  the  pregnant  uterus. 

2.  From  catarrhal  inflammation,  suppurative  inflammation,  or  adhe- 
sive inflammation  of  the  ducts  ;  and  from  cancer  or  other  tumors  at 
the  orifice  or  within  the  duct. 

3.  From  foreign  bodies  within  the  ducts,  as  inspissated  mucus,  gall- 
stones, or  parasites. 

Diagnosis.  Jaundice  due  to  disease  outside  of  the  duets  is  gradual  in 
onset,  varies  in  degree  with  the  amount  of  pressure,  and  becomes 
chronic,  except  in  pregnancy  and  from  faecal  accumulation;  it  may  cause 
death,  or  persist  until  such  termination  results  from  the  primary  disease. 
It  is  recognized  by  the  absence  of  pain;  the  presence  of  disease  in 
other  localities,  indicated  by  its  peculiar  symptoms  and  signs;  the 
absence  of  a  history  of  gallstones;  and,  finally,  by  the  patient's  age. 
In  the  large  majority  of  cases  this  form  of  jaundice  is  due  to  disease  of 
the  pancreas,  particularly  carcinoma. 

Jaundice  due  to  disease  of  the  ducts  presents  various  features.  The 
most  common  form  is  that  due  to  catarrhal  inflammation  of  the  ducts. 
The  jaundice  comes  on  suddenly;  at  least  within  forty-eight  hours  after 
the  onset  of  the  symptoms;  there  is  no  pain,  but  it  is  attended  by 
vomiting  and  other  symptoms  of  mild  gastritis,  and  is  usually  accom- 
panied by  itching.  It  follows  indiscretions  in  diet,  and  occurs  in  young 
subjects.  A  definite  cause  for  the  gastritis  can  usually  be  found.  If 
the  jaundice  is  due  to  suppurative  inflammation  of  the  ducts,  there  is  a 
previous  history  of  gallstones  on  account  of  which  the  suppuration 
took  place.  It  must  not  be  forgotten,  however,  that  other  lesions, 
which  cause  jaundice,  may  cause  suppurative  inflammation  of  the  ducts 
also,  such  as  obstruction  by  external  pressure.  The  course  of  the 
jaundice  is  chronic.  Fever  and  other  symptoms  of  suppuration  attend 
it.  In  adhesive  inflammation  there  is  a  history  of  trauma  from  gall- 
stones, and  the  affection  is  chronic.  In  cancer  of  the  gall-ducts  the 
adveut  of  jaundice  is  slow,  the  course  protracted;  the  symptoms  are 
the  symptoms  of  carcinoma,  to  which  are  often  added  the  symptoms 
of  suppuration.      (See  Disease  of  the"  Gall-ducts.) 

Foreign  bodies  within  the  ducts  cause  jaundice  by  direct  obstruction, 
or  by  the  catarrhal  inflammation  which  their  presence  excites.  The 
symptoms  occur  suddenly  in  the  former  instance,  gradually  in  the 
latter.  The  characteristic  symptoms  of  gallstones  precede  the  jaun- 
dice. The  patient  is  usually  a  woman  past  forty  years,  with  habits  of 
life  which  predispose  to  the  formation  of  calculi. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       631 

Jaundice  due  to  lowering  of  the  blood-pressure  in  the  liver,  so  that 
the  tension  between  the  bile-ducts  and  the  blood-passages  is  altered, 
occurs  suddenly,  is  light  in  degree,  and  is  not  attended  by  marked 
symptoms;  it  is  due  usually  to  shock  or  emotions. 

Hematogenous  jaundice  must  be  distinguished  from  hepatogenous 
jaundice.  In  the  hematogenous  form  the  onset  of  the  jaundice  is 
more  rapid,  the  general  symptoms  are  more  pronounced,  particularly 
the  nervous  symptoms.  With  the  onset  of  discoloration  cerebral 
symptoms  are  observed.  This  is  particularly  the  case  in  acute  yellow 
atrophy  of  the  liver.  The  toxic  forms  of  hematogenous  jaundice, 
in  which  there  is  no  obstruction,  are  not  severe;  the  discoloration  of 
the  skin  is  light  yellow,  and  may  not  even  be  observed  by  the  patient, 
nor  cause  pronounced  symptoms.  The  blood  is  destroyed  rapidly  in 
these  cases,  and,  as  it  cannot  be  disposed  of  by  the  liver,  spleen,  or 
kidneys,  the  transformed  hemoglobin  is  deposited  in  the  tissues.  '  In 
this  class  of  cases  the  urine  contains  but  little  bile-pigment,  but  there 
is  a  large  amount  of  bilirubin  and  indican.  The  stools  are  not  clay- 
colored. 

Infantile  Jaundice.  Jaundice  in  infants  is  due  to  two  causes  : 
First,  congenital  obliteration  of  the  ducts;  and,  second,  catarrhal 
inflammation.  It  must  not  be  confounded  with  the  yellow  discoloration 
of  the  skin  due  to  the  excess  of  coloring-matter  in  the  blood,  which 
is  not  disposed  of  by  the  liver.  In  congenital  obliteration  of  the  gall- 
ducts  jaundice  rapidly  ensues  and  deepens  to  an  intense  degree;  hem- 
orrhages occur,  the  child  becomes  stupid  or  comatose,  may  have  con- 
vulsions, and  death  takes  place  in  coma.  There  is  rapid  emaciation, 
and  the  liver  and  spleen  are  enlarged.  The  child  may  live  many 
months. 

Simple  catarrhal  jaundice  in  infants  is  associated  with  moderate  gas- 
tric disorder.  The  jaundice  is  light;  the  conjunctive  alone  may  be 
discolored.  In  infants  malignant  jaundice  may  be  due  to  inflammation 
of  the  portal  veins,  secondary  to  umbilical  phlebitis.  The  jaundice 
develops  after  suppurative  inflammation  about  the  umbilicus,  and  is 
attended  by  an  increase  of  temperature.  There  may  be  some  tender- 
ness over  the  liver;  frequently  peritonitis  develops  at  the  same  time. 
Pyemic  symptoms  may  set  in,  and  pus  may  be  found  in  other  situa- 
tions. If  the  fever  and  pyemic  condition  do  not  cause  death,  the 
jaundice  becomes  more  pronounced  and  causes  cutaneous  and  mucous 
hemorrhages.  Convulsions  and  coma  are  apt  to  supervene  before  death. 
Jaundice  in  infants  also  occurs  in  interstitial  hepatitis  of  syphilitic 
origin.  The  evidences  of  hereditary  syphilis  are  seen  in  the  skin  and 
mucous  membranes.  The  liver  is  enlarged,  and  there  may  be  tender- 
ness from  perihepatitis. 

Malignant  Jaundice.  Acute  Yellow  Atrophy  of  the  Liver.  Acute 
diffuse  inflammation  of  the  liver  with  necrosis  of  the  cells,  characterized 
by  jaundice  and  cholemia.  It  occurs  very  frequently  during  preg- 
nancy. It  is  most  common  prior  to  the  thirtieth  year.  It  is  said  to 
follow  fright.  The  symptoms  are  local  and  general.  Jaundice  is 
at  first  noticed  after  an  attack  of  gastro-duodenal  catarrh.  It  is  light, 
occasionally  extends  over  the  entire  body,  and  is  not  usually  attended 


632  SPECIAL   DIAGNOSIS. 

by  itching.  Within  twenty-four  or  forty-eight  hours  the  patient  com- 
plains of  headache;  delirium  sets  in  with  stupor  and  convulsions. 
The  headache  is  attended  with  vomiting.  Fever  of  moderate  degree 
begins  at  the  same  time,  although  in  some  cases  it  is  absent.  Although 
the  jaundice  is  not  intense,  the  effects  upon  the  blood  are  early  seen; 
hemorrhages  underneath  the  skin  and  from  the  mucous  membrane  take 
place.  In  pregnant  women  abortion  follows,  the  hemorrhage  from 
which  may  be  very  excessive.  The  stupor  and  delirium  are  followed 
by  coma,  and  death  takes  place  in  the  first  week;  or  coma  may  be 
preceded  by  the  typhoid  state,  and  the  disease  last  longer  than  a  week. 
The  urine  is  bile-stained,  and  contains  albumin  and  casts.  It  dimin- 
ishes in  amount,  and  is  soon  passed  involuntarily.  Leucin  and  ty rosin 
are  always  present.  The  latter  may  be  seen  in  the  sediment,  although 
it  is  more  marked  when  a  few  drops  are  evaporated  on  a  cover-glass. 
The  bowels  are  loose  and  the  stools  involuntary  and  clay-colored. 

On  examination  the  liver  is  found  to  be  diminished  in  size;  this 
may  not  be  appreciated  by  percussion  in  the  anterior  region,  but  in 
the  axillary  region  the  width  is  reduced  one  or  two  inches.  There 
may  be  some  tenderness  over  the  liver  and  over  the  ducts.  The  data 
upon  which  a  diagnosis  is  based  are  the  age,  sex,  pregnancy,  the 
rapidity  of  onset  of  cerebral  symptoms  following  jaundice,  diminution 
in  the  size  of  the  liver,  with  leucin  and  tyrosin  in  the  urine.  It  must 
be  distinguished  from  the  jaundice  of  hypertrophic  cirrhosis  of  the 
liver,  which  at  times  becomes  malignant.  Some  observers  have  thought 
that  acute  yellow  atrophy  may  supervene  upon  this  form  of  cirrhosis, 
thereby  causing  malignant  jaundice;  but  there  is  more  fever  than  in 
atrophy,  while  leucin  and  tyrosin  are  not  found  in  the  urine. 

In  phosphorus-poisoning  the  hemorrhages,  the  jaundice,  and  diminu- 
tion in  the  size  of  the  liver  are  the  same  as  in  acute  yellow  atrophy. 
Gastric  symptoms  are  more  marked,  and  leucin  and  tyrosin  are  not 
present  in  the  urine.  It  must  not  be  forgotten  that  all  cases  of  jaun- 
dice may  terminate  suddenly  with  delirium,  followed  by  coma,  or  by 
the  development  of  the  typhoid  state. 

Fever.  Hepatic  Fever.  In  addition  to  the  symptoms  and  associate 
phenomena  the  occurrence  of  fever  may  be  of  diagnostic  importance 
in  distinguishing  the  various  forms  of  obstructive  jaundice.  Fever 
occurs  frequently  in  jaundice,  but  usually  attends  only  certain  forms. 
In  catarrhal  jaundice  it  is  present  for  three  or  four  days  only,  disappear- 
ing as  the  severe  gastric  symptoms  subside.  In  hepatic  colic,  with  jaun- 
dice, it  is  transitory  and  associated  with  chills  and  sweats.  In  jaundice 
from  obstruction  it  occurs,  first,  when  the  obstruction  is  due  to  gall- 
stones without  secondary  changes  in  the  liver;  second,  in  suppurative 
inflammation  of  the  ducts  produced  by  the  gallstones  or  other  causes. 
Fever  under  these  circumstances  assumes  a  peculiar  form  which,  on 
account  of  its  connection  with  disease  of  the  liver,  is  known  as  inter- 
mittent hepatic  fever  (see  p.  115).  The  intermittent  fever  is  associated 
with  obstructive  jaundice  in  the  following  groups  :  First,  with  each 
paroxysm  of  hepatic  colic  moderate  fever  and  jaundice  are  present. 
The  latter  becoming  more  intense  after  each  paroxysm,  disappears  in  a 
short  time.      The  paroxysmal  attacks  may  recur  at  intervals  for  years. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      633 

Second,  the  hepatic  colic  is  attended  by  distinct  ague-like  paroxysms 
of  chill,  fever,  and  sweat,  after  each  of  which  the  jaundice,  which  con- 
tinues to  the  end,  is  more  intense.  Third,  pain  in  the  liver  and  gastric 
disturbance,  with  fever,  but  without  jaundice.  The  symptoms  occur 
in  distinct  paroxysms.  Gallstones  are  probably  the  cause  in  all  these 
conditions,  leading  in  some  cases  to  chronic  obstruction  of  the  duct 
without  suppuration.  If  suppuration  is  present,  the  symptoms  are 
somewhat  different.  Thus,  (1)  there  is  more  tenderness  in  the  hepatic 
region,  with  enlargement  of  the  gall-bladder;  (2)  the  paroxysms  are 
more  frequent ;  (3)  jaundice  is  not  so  intense  and  and  not  influenced 
by  paroxysms  ;  (4)  the  patient  is  ill  in  the  intervals,  and  there  is  wast- 
ing. There  are  no  periods  of  improvement  locally  or  in  the  general 
condition.  The  most  important  point  in  cases  of  gallstone  is  the  sub- 
sidence of  all  symptoms  between  the  paroxysm  of  fever. 

Intermitting  fever  of  this  character  must  be  distinguished  from 
malaria.  The  history  of  gallstones,  with  pain  in  the  region  of  the 
liver,  and  the  negative  appearance  of  the  blood,  are  sufficient  to  estab- 
lish the  diagnosis. 

Hepatic  fever  also  occurs  in  cancer  when  the  neoplasms  grow  rap- 
idly, in  certain  forms  of  cirrhosis,  and  in  obstruction  from  other  causes 
than  gallstones.  It  is  particularly  common  in  suppurative  inflamma- 
tion of  hydatid  cysts,  or  after  they  rupture  and  discharge  into  the 
biliary  vessels.  Without  previous  knowledge  of  the  hydatid  cyst  the 
diagnosis  is  almost  impossible,  save  that  the  pain  is  less  when  obstruc- 
tion is  due  to  this  cause  than  in  obstruction  from  the  passage  of  gall- 
stones. 

Weil's  Disease.  Acute  febrile  jaundice,  which  rapidly  becomes 
malignant,  occurring  in  butchers,  laborers,  and  brewers,  has  been  de- 
scribed l>y  Weil.  After  exposure  to  cold  generally,  as  in  a  beer-vault, 
the  patient  is  seized  with  a  chill,  followed  by  fever,  with  headache,  vom- 
iting, and  epigastric  pain.  Jaundice  sets  in  rapidly.  The  temperature 
remains  high,  or  may  be  intermitting.  Stupor,  delirium,  and  coma, 
albuminuria  with  suppression  of  urine,  subcutaneous  hemorrhages,  and 
hemorrhages  from  mucous  membranes  rapidly  ensue.  Black  vomit 
occurs  early.  In  one  of  my  cases  there  was  enlargement  of  the  liver 
with  subcutaneous  oedema  over  the  hepatic  area.  The  microscopical 
appearances  were  those  of  acute  diffused  parenchymatous  inflammation. 
In  another,  a  breweryman,  the  liver  was  enlarged,  but  without  unusual 
change,  save  congestion. 

The  delirium  is  sometimes  violent.  The  appearance  and  symptoms 
suggest  acute  yellow  atrophy  of  the  liver.  The  etiological  distinctions 
are  noteworthy :  the  liver  is  not  small ;  leucin  and  tyrosin  are  not  found 
in  the  urine  ;  the  jaundice  is  more  intense.  The  diagnostic  circum- 
stances of  epidemic  and  contagious  diseases  serve  to  exclude  yellow 
fever.     (See  Yellow  Fever.) 

Palpation.  By  palpation  the  lower  border  of  the  liver  can  be 
determined  in  thin  subjects,  or  in  those  in  whom  the  liver  is  greatly 
enlarged.  It  may  be  difficult  to  determine  the  border  when  the  abdo- 
men is  distended  on  account  of  flatulency.     Careful  palpation  must  be 


634  SPECIAL  DIAGNOSIS. 

made  with  the  tips  of  the  fingers,  pressing  them  firmly  inward  along 
the  margin  of  the  ribs,  at  the  same  time  securing  relaxation  of  the 
abdominal  muscles  by  having  the  patient  take  a  full  breath,  and  having 
the  legs  drawn  up  and  the  shoulders  elevated.  The  pressure  should 
be  made  in  the  intervals  following  the  act  of  inspiration.  By  care 
and  patience  the  fingers  can  be  pushed  deeply  inward  and  be  made  to 
feel  the  border  of  the  liver,  even  in  health.  Care  must  be  taken  not 
to  cause  contraction  of  the  right  rectus  muscle,  for  if  this  takes  place 
the  indurated  mass  may  simulate  tumor  or  enlargement  of  the  liver. 
The  left  lobe  of  the  liver,  below  the  ensiform  cartilage,  extends  half- 
way to  the  umbilicus.  Here  it  is  most  accessible  to  palpation.  By 
palpation  we  also  determine  the  size  of  the  gall-bladder  and  the  degree 
of  movement  of  the  liver  in  respiration.  On  full  inspiration  the  liver 
descends,  and  during  the  act  of  expiration  rises  again.  This  mova- 
bility  is  of  service  in  distinguishing  the  liver  from  other  organs  that 
are  fixed  within  the  abdomen. 

In  amyloid  disease  the  lower  edge  is  smooth,  rounded,  the  tissue 
dense  and  unyielding  to  pressure,  and  the  anterior  surface  perfectly 
smooth,  as  a  rule;  but  when  the  liver  is  also  cirrhotic  or  syphilitic 
the  surface  may  be  irregular  and  fissured. 

The  fatty  liver  has  also  a  rounded  smooth  border,  but  its  tissue  is 
not  so  dense  and  resistant,  except  when  cirrhosis  coexists.  Its  surface 
is  smooth. 

In  single  abscess  the  liver  is  enlarged,  but  not  uniformly,  and  not 
invariably.  If  the  abscess  is  located  in  the  right  lobe  and  nearer  the 
anterior  than  the  posterior  surface,  palpation  may  be  able  to  detect  not 
only  enlargement,  but  also  deep-seated  obscure  fluctuation,  surrounded 
by  a  zone  of  hard  tissue.  The  tumor  is  round,  smooth,  tense,  tender, 
and  painful. 

In  multiple  abscesses  the  liver  is  enlarged  uniformly,  and  usually  none 
of  the  abscesses  are  large  enough  to  be  felt  as  a  distinct  prominence. 
The  liver  is  tender  and  painful. 

In  hydatid  tumor  the  degree  of  enlargement  depends  very  much  upon 
the  situation  of  the  cyst,  upon  its  stage  of  development,  and  upon  the 
activity  of  the  echinococci.  Sometimes  the  cyst  is  so  small  that  its 
existence  remains  unsuspected;  at  other  times  the  enlargement  is  so 
great  as  to  fill  the  abdominal  cavity.  As  in  abscess,  the  possibility  of 
detecting  the  tense,  globular,  fluctuating,  painless  tumor  characteristic 
of  the  disease,  depends  upon  its  situation.  If  it  is  on  the  anterior  sur- 
face or  lower  border,  it  is  easily  detected,  especially  if  the  tumor  is  at 
all  large;  but  if  it  projects  from  the  posterior  surface  or  from  the  upper 
or  lateral  borders,  detection  is  difficult,  and  may  be  impossible. 

In  congestion  of  the  liver  the  enlargement  is  not  so  great  as  in  abscess, 
nor  are  pain  and  tenderness  so  pronounced.  Moreover,  the  enlarge- 
ment is  usually  not  permanent.  The  lower  border,  if  it  projects  below 
the  edge  of  the  ribs,  is  smooth. 

In  hypertrophic  cirrhosis  the  enlargement  is  moderate,  the  surface 
smooth,  or  but  slightly  roughened,  denser  than  normal,  and  somewhat 
tender. 

In  cancer  the  enlargement   resembles  that  of   single  abscess  and 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      635 

hydatid  tumor  in  that  it  is  irregular.  But,  unlike  hydatid  tumor,  the 
irregularities  are  due  to  knobs  or  bosses  which  project  from  the  surface 
of  the  liver,  are  usually  entirely  free  from  any  fluctuation,  and  are 
tender  on  palpation.  There  may  be  a  single  large  mass,  or  a  number 
of  knobs  or  nodules.  The  part  projecting  below  the  ribs  may  be  free 
from  any  nodules. 

Palpation  of  the  liver  may  discover  a  friction  from  perihepatitis, 
and  pain  or  tenderness  from  that  cause,  or  from  cancer  or  abscess. 
Pulsation  of  the  liver  may  be  a  transmitted  impulse  from  the  abdom- 
inal aorta  or  a  venous  pulse,  such  as  occurs  also  in  the  jugulars,  from 
tricuspid  regurgitation. 

Floating  liver  is  diagnosticated  by  feeling  in  the  lower,  most  fre- 
quently the  right  portion  of  the  belly,  a  large  tumor  which  may,  how- 
ever, easily  be  confounded  with  tumors  of  other  organs.  It  can  be  dis- 
tinguished as  liver  :  (1)  By  recognizing  the  notch;  (2)  by  the  presence 
of  a  tympanitic  note  in  the  proper  region  of  the  liver,  as  loops  of 
intestine  lie  between  the  diaphragm  and  liver;  (3)  by  the  excessive 
movability  of  the  tumor;  and  (4)  by  the  fact  that  it  is  possible  to 
replace  the  liver;  (5)  by  its  size  and  consistency.  It  occurs  almost 
exclusively  in  women,  possibly  as  the  result  of  a  congenital  lengthen- 
ing of  the  suspensory  ligament,  although  more  likely  from  relaxed 
abdominal  walls.  It  may  be  confounded  with  ovarian  cyst,  typhlitis, 
and  movable  right  kidney  with  hydronephrosis. 

Constriction  of  the  Liver  from  Tight  Lacing  (Schnurleber)  occurs 
chiefly  in  women.  Tight  corsets,  and,  still  more,  tight  waist-straps  or 
bands  squeeze  the  liver  downward,  especially  the  right  lobe,  so  that 
it  can  be  palpated.  In  more  pronounced  cases  a  furrow,  often  palpable, 
is  produced,  and,  below  this,  a  constricted  lobe  which  may  extend  as 
far  down  as  the  anterior  superior  spine  of  the  ilium  and  carry  the  gall- 
bladder with  it.  In  other  instances  the  right  lobe  is  elongated,  ex- 
tending even  to  the  crest  of  the  ilium.1 

Lobes  so  depressed  are  usually  thin  and  easily  movable,  and  can  be 
grasped  with  the  hand  and  moved  to  and  fro.  If  the  lobe  does  not  reach 
so  far  downward,  it  is  more  rounded  and  blunt  in  shape.  It  is  not 
always  easy  to  demonstrate  its  connection  with  the  liver,  because  coils 
of  intestine  lie  over  the  liver  in  the  furrow,  make  palpation  difficult, 
and  cause  a  tympanitic  note  between  the  liver-dulness  and  the  dulness 
of  the  constricted  lobe. 

Confusion  with  tumors  of  other  kinds  can  be  avoided  usually  by 
deep  palpation  or  percussion. 

Gall-bladder.  When  the  gall-bladder  has  a  certain  degree  of 
fulness,  it  may,  accordng  to  Gerhardt,  be  not  only  felt  in  healthy  per- 
sons, if  the  stomach  and  bowels  are  empty,  as  a  smooth,  round,  fluc- 
tuating tumor  at  the  lower  border  of  the  liver,  but  be  even  visible  and 
be  outlined  by  percussion.  If  a  line  is  drawn  from  the  right  acromion 
process  to  the  umbilicus,  it  will  bisect  the  gall-bladder  at  a  point  where 
it  passes  over  the  margin  of  the  ribs.  The  fundus  is  situated  below 
the  edge  of  the  liver,  at  about  the  ninth  costal  cartilage,  just  outside 

1  Musser  :  Transactions  Philadelphia  Pathological  Society,  vol.  x. 


636  SPECIAL  DIAGNOSIS. 

the  edge  of  the  right  rectus  muscle.  Palpation  is  easy  when,  owing 
to  closure  of  the  cystic  duct,  the  gall-bladder  is  distended  with  bile  or 
with  inflammatory  exudate,  or  enlarged  by  thickening  of  its  walls  or 
by  an  accumulation  of  gallstones  A  pear-shaped  tumor  is  then  felt 
which,  if  not  adherent  to  the  border  of  the  liver,  is  movable  with  it. 
In  simple  stasis,  hydrops  vesicae  fellese,  and  purulent  inflammation, 
the  tumor  is  tense  and  elastic;  in  inflammatory  or  carcinomatous 
thickening  of  the  wall,  dense  and  irregular.  Calculi  can  often  be 
recognized  by  the  form  or  hardness  or  by  the  sound  made  by  rubbing 
them  together. 

Aspiration.  We  are  warranted  in  determining  the  nature  of  an 
obscure  enlargement  of  the  liver  or  of  the  gall-bladder  by  aspiration. 
In  abscess,  pus,  in  hydatid  disease,  the  characteristic  fluid  may  be 
withdrawn. 

In  a  case  of  local  enlargement  the  apex  of  the  swelling  should  be 
aspirated.  If  aspiration  is  performed  near  the  upper  border,  the  needle 
should  be  thrust  downward ;  if  near  the  lower  border,  upward.  The 
left  lobe  should  be  aspirated  with  care  in  order  that  the  stomach  be 
not  pierced.     (See  p.  164,  Aspiration  for  Diagnosis.) 

Auscultation.  By  auscultation  we  may  detect  a  friction-sound  in 
perihepatitis;  a  grating  or  rubbing  when  the  gall-bladder  contains  calculi 
if  it  is  palpated;  a  murmuring  continuous  in  tricuspid  regurgitation. 

Percussion.  Alterations  in  Size  and  Shape  of  the  Liver.  The  liver 
may  diminish  in  size,  or  it  may  enlarge.  Diminution  in  Size  can  only 
be  recognized  by  percussion.  The  normal  extent  of  hepatic  dulness  is 
diminished.  ■  This  is  usually  more  marked  in  the  anterior  and  lateral 
regions.  The  diminution  is  due  to  simple  or  acute  yellow  atrophy  of 
the  liver  or  cirrhosis.  It  must  not  be  confounded  with  the  apparent 
diminution  that  takes  place  in  emphysema,  or  that  which  occurs  from 
distention  of.  the  bowels  with  flatus,  as  in  peritonitis.  Absence  of  hepa- 
tic dulness  may  occur  when  there  is  gas  in  the  peritoneal  cavity.  En- 
largement of  the  liver  is  determined  by  inspection,  palpation,  and  per- 
cussion. 

By  percussion  the  size  of  the  liver  is  accurately  made  out.  Any 
marked  increase  of  hepatic  dulness  beyond  the  normal  limits  (see  p. 
628)  usually  means  increase  in  size  of  the  liver.  Both  superficial  and 
deep  percussion  must  be  performed.  The  upper  border  is  determined 
by  percussing  from  a  point  above  the  liver-area  toward  the  liver — 
anteriorly  from  the  third  interspace  downward,  laterally  from  the 
fourth,  and  posteriorly  from  the  angle  of  the  scapula.  In  health 
the  upper  border  of  the  liver  is  found  at  the  fifth  interspace ;  in  the 
axilla,  at  the  sixth;  and  in  the  back,  at  the  ninth  interspace.  Thence 
downward  hepatic  dulness  should  continue  to  the  margin  of  the  ribs. 
It  falls  short  of  this  position  by  at  least  an  inch  in  the  aged,  and  in 
deep-chested  persons  it  may  not  be  more  than  two  inches  in  Avidth  in 
front.  The  width  of  the  liver-dulness  in  the  right  mid-clavicular 
line  is  about  four  inches,  in  the  mid-axillary  line  six  inches,  and  in  the 
mid-scapular  line  three  inches. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       637 

The  entire  liver  may  be  enlarged  and  of  normal  shape  or  its  outline 
may  be  irregular;  again,  the  enlargement  may  be  limited  to  one  lobe. 
Hence  the  area  of  dulness  may  be  increased  in  all  directions,  or  the 
increase  may  be  above  or  below  the  normal  limit,  if  the  normal  shape 
is  preserved.  By  percussion  it  may  be  found  that  the  enlargement  is 
regular  from  increase  in  size  upward  or  downward,  or  increase  in  the 
area  of  dulness  in  both  directions.  On  the  other  hand,  if  the  enlarge- 
ment is  irregular,  the  liver-dulness  may  begin  higher  in  the  anterior 
region  than  in  the  axillary  region,  or  may  extend  beyond  the  margin 
of  the  ribs  in  a  limited  area.  When  the  enlargement  is  limited  to  the 
left  lobe  it  is  revealed  by  increase  in  the  dulness  from  the  xiphoid  car- 
tilage downward  as  far  as  the  umbilicus.  The  entire  middle  region 
to  the  navel  may  be  filled  up  by  the  enlarged  liver. 

Uniform  enlargement  of  the  liver  is  due  to  congestion,  hypertrophic 
cirrhosis,  fatty  degeneration,  amyloid  disease,  leukaemia,  cancer,  and 
sometimes  to  hydatid  disease  and  abscess.  Enlargement  of  one  lobe  of 
the  liver  is  due  to  hydatid  disease,  to  abscess,  or  to  cancer,  in  nearly 
all  cases.  Either  the  right  or  the  left  lobe  may  be  the  seat  of  such 
enlargement. 

Enlargement  in  one  particular  direction  is  due  also  to  the  three  con- 
ditions just  indicated.  Although  in  abscess  or  hydatid  disease  enlarge- 
ment downward  is  the  more  common  one,  it  may  be  directly  upward, 
the  lower  border  of  the  liver  occupying  the  normal  position.  When 
enlargement  of  the  liver  extends  upward  it  is  due  to  a  cyst,  or  an 
abscess  in  the  convex  surface  of  the  right  lobe. 

Irregularity  in  the  shape  of  the  liver-dulness  occurs  in  cancer,  in 
abscess,  and  hydatid  disease.  Notwithstanding  the  apparent  irregu- 
larity, enlargements  of  the  liver  conform  to  its  usual  outline,  with  but 
moderate  variations,  and  always  occupy  the  normal  site  of  the  organ. 

Enlargement  of  the  liver  must  be  distinguished  from  enlargement 
of  organs  in  contiguity  with  the  liver,  and  from  structures  usually  con- 
taining air,  which  have  become  solid  or  non-resonant.  The  enlarge- 
ment must,  therefore,  be  distinguished  from  pleural  effusion,  from 
disease  of  the  lungs  which  causes  dulness  on  percussion,  or  from  dis- 
ease of  the  abdominal  organs  causing  increased  dulness  near  the  hepatic 
region.  Hence,  in  renal  tumors,  in  tumors  of  the  large  intestine  or 
stomach,  in  ovarian  tumors,  in  tumors  due.  to  accumulation  of  freces, 
the  physical  signs  on  percussion  may  simulate  enlargement  of  the  liver. 

Simulated  Enlargement.  It  is  well  to  bear  in  mind  the  conditions  which 
simulate  enlargement  of  the  liver.  Of  these  we  have:  (1)  Congen- 
ital malformation:  the  liver  may  be  of  abnormal  shape,  on  account  of 
which  the  area  of  dulness  will  be  increased  in  a  particular  direction. 
It  may  be  quadrangular  or  rounded.  The  liver  may  be  found  in  the 
right  pleural  sac  in  congenital  diaphragmatic  hernia.  The  increase 
of  dulness  upward  will  simulate  enlargement  of  the  liver.  Congenital 
malformations  may  be  suspected  in  the  absence  of  any  symptoms  of 
hepatic  disease,  or  of  conditions  which  may  cause  other  forms  of  spuri- 
ous enlargement.  Moreover,  the  increased  dulness  will  have  existed 
from  early  life.  (2)  In  rhachitis,  on  account  of  the  malformation  of 
the  chest,  the  position  of  the  liver  may  be  such  that  its  area  will  be 


638  SPECIAL  DIAGNOSIS. 

increased.  For  the  same  reason  the  liver  may  be  felt  below  the 
margin  of  the  ribs.  (3)  Disease  of  the  spinal  column  causes  dislo- 
cation, on  account  of  which  the  liver  may  apparently  be  increased 
in  size. 

(4)  Enlargement  of  the  liver  must  be  distinguished  from  pleural  effu- 
sions. This  is  sometimes  difficult.  The  symptoms  of  the  pulmonary 
affection  must  be  considered.  The  general  conditions  which  cause 
hydrothorax  must  be  borne  in  mind.  The  difficulty  in  distinguishing 
the  two  arises  because  the  dulness  of  each  is  continuous.  In  pleural 
effusion,  however,  there  is  uniform  bulging  of  the  affected  side.  The 
liver  is  not  movable,  the  chest-expansion  is  lessened.  The  upper 
border  of  dulness  of  the  fluid  may  be  movable  if  the  effusion  is  not 
large,  while  the  line  of  dulness  is  S-shaped — that  is,  high  behind  and 
high  in  front.  If  the  effusion  is  large,  the  upper  limit  of  dulness  is 
horizontal.  The  upper  limit  of  dulness  in  the  pleural  effusion  changes 
its  position  in  many  instances.  In  enlargement  of  the  liver  the  lower 
ribs  are  often  everted,  but  in  pleural  effusion  a  depression  may  be  seen 
between  the  lower  margin  of  the  ribs  and  the  upper  surface  of  the 
liver,  if  the  latter  is  dislocated  by  pressure  of  the  fluid.  Sometimes 
enlargements  of  the  liver  give  rise  to  secondary  pleural  effusion,  so 
that  too  often,  after  finding  pleural  effusion,  the  size  of  the  liver  is  not 
estimated.  (5)  Pericardial  effusion  and  dilated  heart  are  said  to  sim- 
ulate enlargement  of  the  liver.  The  history  of  the  case,  the  origin 
and  mode  of  development  of  the  symptoms,  the  physical  signs  of  car- 
diac disease,  point  to  its  true  nature.  (6)  Enlargement  of  the  liver 
may  be  due  apparently  to  subdiaphragmatic  abscess.  The  accumulation 
between  the  liver  and  diaphragm  causes  the  latter  to  be  pushed  down- 
ward. It  is  very  difficult  to  distinguish  the  spurious  from  the  false 
enlargement  in  these  instances.     Aspiration  may  help  in  the  diagnosis. 

(7)  Abnormal  Condition  of  the  Abdominal  Parietes.  Increased  tension 
or  spasm  of  the  recti  muscles,  giving  rise  to  phantom  tumors  of  the 
abdomen,  simulate  enlargement  of  the  liver.  They  occur  in  young 
girls,  and  are  associated  with  gastro-intestinal  catarrh  and  symptoms 
of  hysteria.  Anaesthesia  must  often  be  employed  to  disperse  the 
swelling.  (8)  Tight  lacing.  This  may  displace  the  liver  upward  or 
downward,  according  to  the  direction  of  the  pressure.  It  may  also, 
by  exerting  lateral  compression,  bring  more  of  the  liver  into  contact 
with  the  anterior  abdominal  wall.  And  finally,  if  the  constriction 
has  been  by  a  strap  or  tight  cord,  a  portion  of  the  liver  may  be  more 
or  less  detached  and  appear  as  a  movable  tumor. 

(9)  Some  enlargements  of  the  abdominal  contents  cause  spurious 
enlargement  of  the  liver.  In  the  same  way  increased  abdominal 
pressure  (ascites,  tympanites,  etc.)  causes  the  liver  to  rise  higher  than 
normal,  a.  The  accumulation  of  faeces  in  the  colon.  This  causes  con- 
tinuance of  liver-dulness  downward,  on  account  of  which  it  may  be 
thought  that  the  patient  has  liver  disease.  A  purgative  must  be  given. 
b.  An  ovarian  cyst.  c.  The  presence  of  ascites.  Exclusion  of  the 
latter  is  sometimes  difficult  because  the  ascites  may  be  loculated  and 
situated  in  the  hepatic  region.  It  may  give  rise  to  symptoms  of  he- 
patic enlargement.    Probably  aspiration  alone  can  establish  the  diag- 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      639 

nosis.     Ascites  should  be  easily  distinguished  by  the  physical  signs 
and  the  result  of  exploratory  puncture. 

d.  Tumors  of  the  omentum,  chiefly  tuberculous,  may  occupy  such 
relation  to  the  liver  as  to  increase  the  dulness  downward.  The  history, 
the  occurrence  of  the  omental  tumor,  with  symptoms  of  tuberculosis, 
may  aid  in  determining  the  true  condition. 

e.  In  tumors  of  the  kidney,  which  simulate  enlarged  liver,  it  is 
found  that  the  edge  of  the  liver  cannot  well  be  felt,  but  Murchison 
thinks  the  fingers  can  usually  be  inserted  between  the  ribs  and  the 
upper  part  of  the  renal  tumor.  The  renal  tumor,  however,  is  not 
fixed.  It  is  rounded  on  every  side;  it  has  the  shape  of  a  kidney. 
The  urine  should  be  examined. 

/.  Enlargements  of  the  liver  must  be  distinguished  from  pancreatic 
cyst,  or  effusion  in  the  lesser  peritoneal  cavity.  This  can  usually  be 
accomplished  with  ease,  except  in  hydatid  disease  of  the  left  lobe  near 
the  suspensory  ligament.  In  effusion  of  the  lesser  peritoneal  cavity 
the  tumor  occupies  the  left  upper  quadrant,  and  may  extend  as  low  as 
the  transverse  umbilical  line.  It  causes  dislocation  of  the  heart,  so 
that  the  apex  is  as  high  as  the  third  interspace,  and  beyond  the  mid- 
clavicular line.  It  is  accompanied  by  an  increase  in  the  dulness  pos- 
teriorly, so  that  the  upper  limit  may  extend  to  the  angle  of  the  left 
scapula.     Puncture  may  furnish  the  necessary  information. 

The  presence  or  absence  of  pain  may  sometimes  furnish  a  clue  to  the 
nature  of  the  enlargement  of  the  liver.  Murchison  considers  this  a 
reliable  distinction.  Painless  enlargements  of  the  liver  are  due  to 
passive  congestion,  to  hydatid  disease,  to  fatty  and  amyloid  disease 
of  the  liver.  Painful  enlargements  of  the  liver  are  seen  in  abscess, 
cancer,  and  syphilitic  disease,  with  perihepatitis. 

In  children  the  lower  border  of  the  liver  is  normally  lower  than  in 
adults,  because  the  liver  is  itself  proportionately  larger.  For  the 
same  reason  the  upper  border  is  at  a  higher  level. 

Diseases  of  the  Liver.     The  Fatty  Liver. 

The  symptoms  of  fatty  liver  are  not  pronounced.  The  physical 
sign  is  a  uniform  enlargement  extending  in  all  directions.  On  pal- 
pation the  edges  can  be  felt;  they  are  rounded  and  smooth.  They 
are  soft  at  first,  but  later  become  indurated.  Fatty  liver  may  be 
followed  by  cirrhosis  after  a  period  of  alcoholism.  The  general 
symptoms  are  those  of  the  primary  disease.  Fatty  liver  occurs  in 
gouty  subjects,  but  is  notably  present  in  wasting  diseases,  in  tuber- 
culosis, in  chronic  hip-joint  disease,  and  in  amyloid  disease  of  the 
liver. 

Fatty  liver  sometimes  follows  the  congestion  of  the  liver  which  is 
present  in  the  course  of  organic  heart  disease.  It  is  not  a  true  fatty 
liver,  but  a  fatty  cirrhosis.  There  is  increased  fatty  degeneration  with 
an  overgrowth  of  connective  tissue.  This  form  is  associated  with  heart 
and  kidney  disease.  On  palpation  the  edges  of  the  liver  arc  indurated. 
The  liver  may  undergo  diminution  in  size  later,  and  the  symptoms  of 
cirrhosis  ensue. 


640  SPECIAL  DIAGNOSIS. 

Amyloid  Disease  of  the  Liver. 

Disease  of  the  liver  attended  by  enlargement  without  pain  is  often 
due  to  amyloid  disease.  Similar  disease  is  found  in  other  organs,  and 
there  is  present,  to  point  to  the  nature  of  the  enlargement,  bone  disease, 
prolonged  suppuration,  or  tuberculosis.  In  amyloid  disease  the  pallor 
of  the  patient  is  pronounced,  the  face  may  be  swollen,  and  the  ankles 
slightly  oedematous.  The  spleen  is  enlarged,  the  urine  albuminous 
and  abundant,  but  of  moderate  specific  gravity.  In  amyloid  disease  a 
history  of  syphilis  is  an  important  point  in  establishing  the  diagnosis. 
Fatty  liver  can  readily  be  distinguished  from  amyloid  disease  by 
palpation.  In  amyloid  disease  the  surface  is  smooth,  but  very  much 
indurated. 

Cancer  of  the  Liver. 

The  setiological  factors  upon  which  the  diagnosis  of  cancer  is  based 
are  :  the  age  of  the  patient — most  frequently  between  the  fortieth  and 
sixtieth  year;  the  female  sex,  in  a  measure;  aud  heredity.  The  disease 
is  nearly  always  secondary  to  cancer  in  some  other  situation;  conse- 
quently, in  cases  in  which  symptoms  point  to  cancer  of  the  liver,  search 
must  be  made  for  the  primary  lesion  elsewhere.  The  most  frequent 
seat  is  the  rectum,  the  uterus,  the  stomach,  the  remainder  of  the  ga>tro- 
intestinal  tract.  The  eye  has  been  removed  for  obscure  disease,  and 
symptoms  of  carcinoma  of  the  liver  have  subsequently  developed. 
The  nature  of  the  hepatic  symptoms  was  obscure  during  life,  but  at  the 
post-mortem  examination  melanotic  sarcoma  was  found;  the  primary 
lesion  undoubtedly  had  been  in  the  eye.  Further  aetiological  influences 
that  may  bear  upon  the  diagnosis  are  :  1,  the  occurrence  of  gallstones, 
which  act  as  the  exciting  cause  in  the  development  of  primary  cancer 
of  the  ducts,  thence  spreading  to  the  liver;  2,  the  occurrence  of 
trauma. 

The  symptoms  of  cancer  of  the  liver  may  be  due  to  (1)  increase  in 
size  of  the  liver  ;  (2)  to  pressure  of  the  growths  upon  the  ducts  or 
terminal  portal  vessels  ;  and  (3)  to  the  general  effects  of  carcinoma 
upon  the  system — the  cachexia.  The  liver  is  enlarged  and  its  surface 
irregular.  The  organ  can  be  made  out,  by  palpation,  extending  below 
the  margin  of  the  ribs.  The  edges  are  irregular,  and,  on  the  surface, 
bosses  can  be  distinctly  felt.  In  rare  cases  one  or  two  masses  only 
may  be  present,  growing  out  of  the  substance  of  the  left  lobe  of  the 
liver,  causing  a  large  tumor  below  the  sternum.  The  nodules  are 
usually  hard,  but  sometimes  may  be  soft  and  even  fluctuate.  After 
emaciation  becomes  marked  the  nodules  can  be  seen  as  well  as  felt 
near  the  surface  of  the  skin,  and  their  number  distinctly  made  out. 
The  abdomen  is  distended. 

The  liver  is  movable  with  inspiration  ;  progressive  enlargement  can 
be  noted  while  under  observation.  By  percussion  the  enlargement  can 
be  well  defined,  and,  while  the  surface  is  irregular,  the  general  shape 
of  the  dulness  corresponds  to  that  of  the  liver.  The  increased  size 
and  iuflammation  of  the  capsule  cause  a  sensation  of  weight  in  the 
hepatic  region  and    pain    which   may  be  intermitting    in    character. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      641 

The  nodules  may  be  tender  on  palpation.  The  superficial  veins  are 
enlarged. 

In  not  every  instance  do  we  find  enlargement.  In  some  cases  the 
cancer  is  associated  with  cirrhosis  of  the  liver,  or  may  itself  be  of  a 
nodular  type,  and  in  the  course  of  the  disease  undergo  shrinkage.  The 
liver  is  then  normal  or  diminished  in  size,  as  indicated  by  percussion. 

The  symptoms  that  attend  cancer  are:  1.  Jaundice,  which  is  not 
very  deep  unless  the  common  duct  is  affected.  2.  Ascites,  which  is 
always  present  in  the  atrophic  forms,  but  may  be  absent  when  the  liver 
is  enlarged.  3.  The  general  symptoms  are  those  of  rapid  emacia- 
tion, prostration,  and,  in  some  instances,  moderate  fever;  fever  attends 
the  rapidly  growing  cases.  It  is  usually  continuous,  but  may  be  inter- 
mittent, especially  if  there  is  suppuration  or  suppurative  inflammation 
of  the  ducts.  It  is  a  well-known  fact  that  gallstones  are  of  common 
occurrence  in  patients  suffering  from  cancer  in  any  location  whatever. 
The  symptoms  of  biliary  calculus  or  of  obstruction  may  attend  those 
of  secondary  cancer  of  the  liver,  and  the  stone  bears  an  setiological 
significance. 

In  many  instances  secondary  cancer  of  the  liver  may  be  present 
without  symptoms  to  attract  attention  to  this  organ  during  life.  If 
cancer  in  other  regions  has  continued  for  the  usual  period  of  time,  it 
is  almost  certain  that  at  the  autopsy  cancer  of  the  liver  will  be  found 
to  be  present. 

Diagnosis.  The  diagnosis  of  cancer  of  the  liver  is  not  difficult 
when  the  changes  in  the  liver  can  be  made  out  on  palpation  and  percus- 
sion. In  rare  instances,  in  which  the  liver  is  smooth,  it  may  be  mis- 
taken for  fatty  or  amyloid  liver.  A  definite  cause  can  usually  be 
assigned  for  the  latter,  while  the  occurrence  of  jaundice,  the  rapid 
increase  in  size  of  the  liver,  and  the  general  symptoms  of  the  cancer- 
ous cachexia  indicate  cancer  of  the  liver.  The  syphilitic  live?'  with 
irregular  gummata  may  cause  serious  doubt;  the  history  of  the  case 
and  other  signs  of  syphilis  aid  in  the  diagnosis.  Locally  the  condition 
may  exactly  simulate  carcinoma.  The  jaundice,  however,  is  not  so 
frequent  in  occurrence,  or  so  deep  in  syphilitic  gummata;  the  cachexia 
does  not  ensue,  but  the  therapeutic  test  may  be  essential  in  order  to 
make  a  diagnosis. 

In  hypertrophic  cirrhosis  of  the  liver  the  jaundice  is  deep  and  the 
liver  enlarged;  but  there  is  little  wasting  or  anaemia.  The  surface  of 
the  liver  is  smooth;  there  are  certainly  no  bosses,  and  the  organ  is 
painless.  Ascites  is  more  common  in  cirrhosis;  the  patient  is  usually 
affected  earlier  in  life  than  in  cancer. 

In  a  large  growing  cancer  one  or  two  of  the  nodules  may  suppurate 
and  simulate  abscess  of  the  liver.  Ab-cess  follows  a  definite  cause 
usually,  and  occurs  in  early  life;  cancer  is  secondary  to  disease  in  other 
organs  and  occurs  usually  in  late  life.  The  results  of  aspiration  differ 
in  each.  Moreover,  a  history  of  dysentery,  the  occurrence  of  pain, 
of  profound  anaemia,  of  pronounced  hectic  fever  with  irregular  enlarge- 
ment of  the  liver,  but  without  jaundice  or  cachexia,  point  to  abscess. 

Cancer  of  the  liver  may  be  simulated  by  cancer  of  organs  in  close 
proximity  to  the  liver,  as  the  pancreas,  the  pyloric  end  of  the  stomach, 

41 


642  SPECIAL  DIAGNOSIS. 

or  the  colon.  In  pyloric  cancer  the  symptoms  of  dilatation  of  the 
stomach  are  present;  the  percussion-note  is  not  dull,  but  there  is  a  dull 
tympany  over  the  tumor;  it  is  attended  by  vomiting  and  possibly 
hemorrhage  from  the  stomach.  Jaundice  occurs  late.  Cancer  of  the 
pyloric  end  is  not  movable  with  respiration  unless  it  becomes  adherent 
to  the  liver.  Cancer  of  the  omentum  and  colon  are  not  modified  by 
respiration.  The  percussion-note  over  them  is  different;  they  fre- 
quently extend  beyond  the  liver-confines  and  are  associated  with  symp- 
toms of  obstruction  of  the  bowels.  Fo&cal  accumulation  in  the  trans- 
verse colon  must  not  be  mistaken  for  cancer  of  the  liver.  The  large 
masses  adjacent  to  the  liver  may  closely  simulate  cancerous  nodules. 
In  doubtful  cases  the  colon  should  be  emptied.  Cancer  of  the  liver  and 
hydatid  disease  must  not  be  confounded.  The  tumor  in  hydatid  dis- 
ease is  usually  single;  it  is  large  and  may  fluctuate  or  yield  the  hydatid 
fremitus.  It  causes  irregular  enlargement  of  the  liver  when  the  tumor 
presents  in  the  epigastrium  or  along  the  margin  of  the  ribs.  It  is 
painless.     Aspiration  yields  the  characteristic  hydatid  fluid. 

Cancer  of  the  bile-ducts  cannot  always  be  distinguished  from  cancer 
of  the  liver.  Jaundice  early  iu  the  course  of  the  disease,  in  a  person 
who  has  had  gallstones,  followed  by  enlargement  of  the  liver  and 
gall-bladder,  in  the  absence  of  primary  disease  elsewhere,  suggests 
cancer  of  the  gall-bladder  or  ducts.  This  is  more  or  less  confirmed  if 
the  smooth  and  painless  gall-bladder  becomes  hard,  irregular,  and 
tender  on  pressure.  Cancer  of  the  pancreas  also  presents  difficulties; 
a  tumor  in  the  mid-costal  region,  however,  with  vomiting  and  the  early 
development  of  jaundice,  before  the  liver  has  become  enlarged  or  nod- 
ular, and  .associated  with  other  characteristic  symptoms,  such  as  intes- 
tinal dyspepsia  and  fatty  stools,  points  to  the  pancreas  as  the  primary 
seat  of  the  disease. 

Cirrhosis  of  the  Liver. 

A  diffuse  interstitial  inflammation  of  the  liver,  chronic  induration, 
usually  with  atrophy  of  the  organ,  is  caused,  in  the  large  majority  of 
cases,  by  irritants  which  enter  the  portal  circulation  through  the  stom- 
ach. Of  the  irritants  alcohol  is  the  most  common,  and  particularly  the 
stronger  liquors,  as  gin  and  whiskey.  Other  irritants,  as  spices  used 
to  excess,  may  likewise  cause  the  diffuse  inflammation.  Cirrhosis  of 
the  liver  may,  however,  be  a  sequel  to  the  infectious  diseases,  notably 
scarlatina,  and  may  be  incited  by  malaria.  The  infectious  forms  of  cir- 
rhosis usually  lead  to  atrophy  of  the  liver. 

Another  form  is  due  to  obstruction  of  the  bile-ducts,  with  secondary 
overgrowth  of  the  connective  tissue.  It  is  known  as  hypertrophic  or 
biliary  cirrhosis.  In  addition,  cirrhosis  of  the  liver  may  arise  in  the 
course  of  syphilis  ;  the  histological  characteristics  are  different  from 
those  of  true  cirrhosis.  This  does  not  include  the  secondary  cirrhosis 
of  the  liver  which  arises  in  the  course  of  passive  congestion  of  that 
organ,  on  account  of  which  the  so-called  nutmeg-liver  develops. 

Cirrhosis  of  the  liver  of  the  atrophic  form,  due  to  alcohol,  presents 
various  clinical  features.    In  the  first  place,  it  may  exist  without  causing 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      643 

any  symptoms  whatever  during  life.  It  may  be  found  after  death  from 
other  causes,  or  it  may  not  present  symptoms  until  an  accident  occurs 
in  the  course  of  the  disease,  as  hemorrhage  from  some  portion  of  the 
collateral  circulation.  In  both  cases  the  symptoms  are  absent  because 
the  collateral  circulation  is  complete.  If  this  is  incomplete,  however, 
grave  symptoms,  local  and  general,  ensue. 

Before  detailing  them  it  may  be  well  to  state  that  the  occurrence  of 
one  symptom,  which  we  have  termed  accidental,  may  lead  to  the  infer- 
ence that  cirrhosis  of  the  liver  is  present,  particularly  if  the  patient 
has  been  an  alcoholic.  This  symptom  is  hemorrhage.  It  may  be  of 
the  stomach,  causing  death  at  once,  or  after  repeated  hemorrhages; 
it  may  also  take  place  from  the  intestine. 

The  Symptoms  of  Cirrhosis.  The  symptoms  are  general,  due  to  inter- 
ference with  the  nutrition  of  the  patient ;  and  local,  which  depend  upon 
the  degree  of  obstruction  to  the  portal  circulation.  General  symptoms 
rarely  occur  unless  the  local  symptoms  are  present,  as  the  latter  cause 
malnutrition  and  mal-assimilation  from  interference  with  the  gastro- 
intestinal digestion. 

The  symptoms  have  been  divided  into  those  of  the  first  stage,  or 
stage  of  enlargement,  and  those  of  the  second  stage,  or  contraction. 
The  so-called  first  stage  is  not  always  observed. 

During  the  first  stage  the  symptoms  are  those  of  gastritis,  with 
enlargement  of  the  liver.  The  gastric  symptoms  are:  morning  retch- 
ing or  vomiting,  with  discharge  of  mucus,  associated  with  other  symp- 
toms of  gastric  catarrh,  as  loss  of  appetite,  nausea,  tenderness  in  the 
epigastrium,  eructations,  and  constipation,  with  loss  of  flesh  and 
strength.      The  liver  is  enlarged,  but  the  outline  is  regular. 

During  the  second  stage  more  severe  symptoms  arise,  due  to  obstruc- 
tion of  the  portal  capillaries.  The  abdomen  becomes  distended  and 
a  sensation  of  weight  and  pressure  is  complained  of.  On  examination 
ascites  is  detected.  This  may  be  enormous,  causing  monstrous  disten- 
tion, with  pouting  of  the  umbilicus.  The  spleen  is  found  to  be  enlarged, 
extending  over  twice  or  three  times  the  normal  area  on  percussion. 
If  ascites  does  not  interfere,  the  edge  of  the  spleen  can  be  readily 
made  out.  The  portal  obstruction  causes  secondary  gastro-iutestinal 
catarrh,  if  it  was  not  already  present  on  account  of  the  alcoholism. 
Although  constipation  is  usually  present,  there  may  be  persistent  diar- 
rhoea, usually  lienteric  and  occurring  in  the  morning  only.  Hemor- 
rhages may  take  place  from  the  gastro-intestinal  tract  at  any  time, 
either  from  the  stomach  or  the  intestine.  Not  infrequently  they  occur 
from  the  oesophagus,  due  to  varicosity  of  the  veins  at  the  junction  of 
the  oesophagus  and  the  cardiac  end  of  the  stomach.  Hemorrhoids  are 
always  present  and  may  bleed  at  each  stool.  Jaundice  is  not  the  rule, 
and,  if  present,  is  usually  light  and  due  to  the  duodenal  catarrh.  The 
skin  has  a  yellowish  tinge  or  only  a  grayish-earthen  color. 

Physical  Examination.  This  may  be  rendered  difficult  before  para- 
centesis is  performed  by  the  extensive  ascites.  The  enlarged  liver  of 
the  first  stage  will  be  found  to  have  undergone  contraction,  although 
diminution  in  the  area  of  "dulness  is  not  by  any  means  as  absolutely 
confirmative  of  contraction  as  the  opposite  condition  is  of  hypertrophy. 


644  SPECIAL  DIAGNOSIS. 

Percussion  should  be  performed  several  times,  because  the  distended 
intestinal  coils  may  affect  the  results. 

With  the  distention  of  the  abdomen  enlargement  of  the  superficial 
veins  is  also  observed.  This  may  be  very  pronounced,  particularly 
about  the  umbilicus.  The  enlarged,  swollen  mass  of  veins  in  this 
situation  has  been  called,  from  its  appearance,  the  caput  Medusae. 

The  general  symptoms  of  cirrhosis,  and  particularly  the  symptoms 
of  the  later  stages,  are  striking  and  diagnostic.  The  nutrition  is  much 
impaired.  The  patient,  who,  in  the  large  majority  of  cases,  had  been 
corpulent,  becomes  emaciated.  The  skin  changes  in  color  and  becomes 
of  an  earthy-gray  or  dirty- sallow  hue.  The  capillary  venules  of  the 
face  are  dilated;  the  distended  capillaries  on  the  nose  are  distinct. 
Later,  ecchymoses  may  occur  in  the  skin,  and  hemorrhages  take  place 
from  the  mucous  membrane  and  into  the  retina.  Debility  ensues; 
oedema  of  the  ankles  is  almost  sure  to  occur,  and  sometimes  general 
anasarca  may  take  place.  It  is  extremely  rare  to  have  fever  unless 
complications  occur.  The  pulse  is  small  and  becomes  more  rapid  than 
normal;  the  heart-sounds  grow  weaker.  The  skin  may  be  the  seat 
of  eruptions,  and  chronic  skin  diseases  of  various  kinds  develop. 

The  urine  throughout  the  disease  presents  no  characteristics;  as 
ascites  develops,  it  becomes  scauty  aud  dark,  and  loaded  with-  urates 
and  uric  acid.  In  rare  instances  it  may  contain  sugar,  and,  if  the  uric 
acid  is  in  excess,  albumin. 

Collateral  Circulation.  The  collateral  circulation  that  develops  in 
order  that  the  portal  blood  may  reach  the  right  heart  takes  place  iu 
various  ways.  First,  communication  may  be  formed  between  the  veins 
of  the  mesentery  and  those  of  the  abdominal  walls;  second,  between 
the  coronary  veins  of  the  stomach  and  the  veins  of  Glisson's  capsule 
and  the  phrenic  veins;  third,  between  the  internal  hemorrhoidal  and 
the  hypogastric  veins  ;  fourth,  enlargement  of  the  obliterated  umbilical 
vein  iu  the  li game j turn  teres  may  take  place. 

In  the  study  of  a  case  of  cirrhosis  of  the  liver  a  judgment  as  to 
its  nature  may  be,  in  a  measure,  confirmed  by  the  presence  of  other 
phenomena  due  to  the  same  cause.  Very  frequently  we  have,  at  the 
same  time,  cirrhosis  of  the  kidneys  and  sclerosis  of  the  arteries,  with 
secondary  atheroma,  both  of  which  have  led  to  hypertrophy  of  the 
heart.  Striimpell  refers  to  the  occurrence  of  cirrhosis  and  chronic 
tubercular  peritonitis.  He  thinks  the  former  is  the  primary  lesion 
which  predisposes  to  the  development  of  the  latter.  The  course  of  the 
disease  is  prolonged. 

The  dilation  cannot  be  determined  accurately,  as  the  onset  is  usually 
insidious.  After  the  ascites  appears  the  duration  may  vary  from  six 
to  eighteen  months.  Of  course,  this  depends  largely  upon  the  com- 
pleteness of  the  compensatory  circulation.  Death  usually  occurs  from 
intercurrent  disease  or  progressive  exhaustion.  In  not  a  few  cases  cere- 
bral symptoms  occur.  In  addition  to  the  cirrhotic  cachexia,  the  sudden 
occurrence  of  coma  and  convulsions,  preceded  by  delirium,  may  ensue; 
the  cause  of  this  is  not  fully  known.  It  must  be  borne  in  mind  that 
the  occurrence  of  these  symptoms  in  an  alcoholic  subject  may  be  due 
to  a  cirrhosis,  the  presence  of  which  had  not  been  suspected  during  life. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      645 

Diagnosis.  The  diagnosis  is  usually  not  difficult  if  the  complete 
picture  of  the  case  is  presented.  It  cannot  be  established  positively 
without  definite  knowledge  of  the  cause.  If  the  patient  comes  under 
observation  after  ascites  has  developed,  the  diaguosis  is  more  difficult. 
It  must,  in  the  majority  of  cases,  be  based  upon  exclusion  of  heart, 
lung,  and  kidney  disease.  A  history  of  alcoholism  and  the  presence 
of  other  symptoms  of  liver  disease  point  to  the  hepatic  origin  of  ascites. 
Ascites  may  be  due  to  other  causes  within  the  abdomen,  notably  chronic 
peritonitis,  exclusion  of  which  is  sometimes  difficult.  The  general  ten- 
derness, the  less  marked  distention  of  the  abdomen,  and  the  absence 
of  enlargement  of  the  spleen  point  to  peritonitis.  The  fatty  cirrhotic 
liver  may  present  symptoms  similar  to  those  of  the  atrophic  form,  except 
that  it  is  enlarged. 

Hypertrophic  cirrhosis,  or  so-called  biliary  cirrhosis,  presents  a  some- 
what different  picture.  In  the  first  place,  the  cause  is  different.  There 
is  a  history  of  gallstones,  or  obstruction  of  the  duct  from  other  causes. 
The  liver  is  uniformly  enlarged,  and  the  surface  is  irregular  and  strik- 
ingly indurated.  There  are  weakness  and  loss  of  appetite.  Jaundice 
ensues  very  early,  or  may  be  the  first  symptom.  It  increases  and  per- 
sists throughout  the  course  of  the  disease.  Ascites  is  very  slight 
or  absent  altogether.  The  enlargement  and  jaundice  may  continue  for 
months  or  even  years  without  the  development  of  grave  symptoms. 

Fever  may,  however,  set  in  at  any  time,  being  in  all  probability  due 
to  the  biliary  obstruction.  It  is  continuous;  the  temperature  rises 
from  102°  to  104°;  the  tongue  becomes  dry  and  brown,  the  pulse 
rapid.  All  the  symptoms  of  febrile  jaundice  ensue.  The  patient  may 
be  seized  with  convulsions  in  the  course  of  the  disease,  folloAved  by 
coma  and  death.  Most  authorities  state  that  the  enlargement  persists 
throughout  the  course  of  the  disease,  but  some  observers  say  that  after 
a  long  period  of  enlargement,  with  jaundice,  contraction  of  the  liver 
takes  place,  with  symptoms  of  portal  obstruction.  Then  the  spleen 
may  become  enlarged  and  ascites  take  place,  while  the  symptoms  of 
digestive  disturbances  become  more  prominent.  There  may  be  ner- 
vous symptoms,  due  to  acute,  diffuse  necrosis  (acute  yellow  atrophy) 
setting  in  in  the  course  of  the  disease. 

The  diagnosis  is  often  difficult.  Gradual  and  persistent  jaundice 
without  cause,  continuing  for  a  long  time,  associated  with  persistent 
enlargement  of  the  liver  without  symptoms  of  portal  obstruction  in 
the  non-alcoholic  subject,  points  pretty  certainly  to  hypertrophic  cir- 
rhosis of  the  liver. 

Syphilitic  Disease  of  the  Liver. 

Syphilitic  disease  of  the  liver  may  result  in  cirrhosis,  or  in  the  devel- 
opment of  gummata.  Syphilitic  cirrhosis  presents  the  same  symptoms 
as  the  alcoholic  form.  The  history,  the  more  marked  irregularity  on 
the  surface  or  the  liver,  and  the  existence  of  syphilis  elsewhere  may 
lead  to  a  diagnosis  of  the  true  condition. 

In  congenital  syphilitic  disease  of  the  liver  the  inflammation  is  diffuse; 
the  liver  is  enlarged  and  hard;  the  surface  is  smooth;  there  are  usu- 


646  SPECIAL  DIAGNOSIS. 

ally  syphilitic  lesions  in  other  organs;  the  patient  presents  syphilitic 
eruptions,  and  has  the  well-known  wizened  appearance  that  belongs  to 
this  affection. 

Syphilitic  gummata  in  the  liver  may  exist  without  presenting  any 
symptoms  whatsoever,  or  they  may  reveal  their  presence  by  pain  and 
a  localized  swelling  and  discomfort,  which  call  the  patient's  attention 
to  the  region,  particularly  if  his  general  health  is  reduced  at  the  same 
time.  Tumors  are  situated  in  the  left  lobe,  in  the  median  line,  or  along 
the  margin  of  the  ribs.  The  pain  is  usually  localized  in  this  region, 
but  may  extend  more  or  less  over  the  entire  liver,  particularly  if  there 
is  general  perihepatitis  along  with  other  evidences  of  syphilis;  the 
latter  are  not  always  present,  however.  If  the  temperature  is  taken  fre- 
quently, a  moderate  febrile  range  will  be  observed.  It  may  not  rise 
above  100J°,  but  in  the  absence  of  other  causes  it  is  a  valuable  diag- 
nostic symptom.1  In  other  instances  the  gummata  may  grow  in  such 
situation  as  to  interfere  with  the  portal  circulation,  or  press  upon  the 
gall-ducts.  The  latter  is  very  rare.  If  the  gummata  are  felt,  they 
appear  as  enlarged  bosses  which  give  the  sensation  of  flattened  hemi- 
spheres. Sometimes  several  separate  elevations  can  be  made  out  on  the 
surface  of  the  enlarged  organ.  To  determine  the  exact  nature  of  the 
lesion  is  often  very  difficult.  The  symptoms  may  conclusively  point 
to  hepatic  disease.  Knowledge  of  the  presence  of  syphilis  or  alcohol- 
ism aids  in  the  diagnosis.  If  without  a  syphilitic  history,  there  are 
scars  in  the  throat,  nodes  on  the  bones,  or  other  signs  of  syphilis,  the 
conclusion  will  be  modified.  Severe  pain  is  more  prominent  in  syph- 
ilis than  in  cirrhosis,  and  the  nodules  of  syphilis  are  very  different 
from  the  granular  surface  of  cirrhosis. 

Abscess  of  the  Liver. 

Two  forms  are  seen:  tropical  abscess,  so  called,  in  which  one  or  two 
abscesses  are  found;  and  multiple  abscesses,  found  throughout  the 
liver-structure.  The  single  or  solitary  abscess  usually  occurs  in  the 
course  of  dysentery,  and,  in  all  probability,  in  the  amoebic  form  only. 
A  single  abscess  may  also  be  due  to  traumatism,  particularly  in  chil- 
dren. Multiple  abscesses  occur  secondarily  to  inflammation  somewhere 
in  the  portal  area.  Inflammation  and  abscess  about  the  rectum,  inflam- 
mation of  the  appendix,  ulceration  anywhere  in  the  gastro-intestinal 
tract  may  be  followed  by  multiple  hepatic  abscesses.  The  abscesses, 
however,  do  not  occur  directly  by  means  of  emboli,,  as  in  the  case  of 
amoebic  abscess,  but  after  inflammation  of  the  portal  vein  or  suppura- 
tive pylephlebitis.  Multiple  abscesses  of  the  liver  also  follow  obstruc- 
tion and  suppurative  inflammation  of  the  biliary  passages  (suppurative 
cholangitis). 

Tropical  abscess  or  amoebic  abscess  varies  in  its  clinical  course.  In 
a  typical  case  the  clinical  picture  is  that  of  the  general  symptoms  of 
suppuration  setting  in  in  the  course  of,  or  soon  after,  an  exacerbation 
of  amoebic  dysentery,  with  local  symptoms  referred  to  the  liver. 

1  The  Diagnostic  Importance  of  Fever  in  Late  Syphilis.    Musser  :  University  Medical  Magazine, 
October,  1892. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      647 

Symptoms.  The  general  symptoms  are  those  of  intermittent  fever, 
paroxysms  of  which  uiay  occur  daily  or  only  every  second  day,  attended 
by  chill,  fever,  and  sweat.     The  fever  may  be  remittent  or  continuous. 

The  local  symptoms.  Pain  in  the  region  of  the  liver;  this  may  be 
referred  to  the  region  of  the  right  or  left  lobe.  It  may  be  seated  in 
the  fifth  or  sixth  interspaces  anteriorly,  or  behind  at  the  ninth  and 
tenth  ribs.  There  may  be  pain  in  the  right  shoulder.  The  pain  may 
be  paroxysmal,  or  it  may  be  intense  and  persistent. 

Fig.  114. 


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Intermittent  fever  in  abscess  of  the  liver. 


Physical  Examination.  On  examination  the  liver  is  enlarged.  The 
enlargement  may  be  uniform;  if  the  abscess  is  central,  the  entire  organ 
takes  part  in  the  swelling;  on  the  other  hand,  it  may  be  an  enlarge- 
ment upward  in  the  anterior,  the  axillary,  or  the  posterior  region.  If 
the  convex  surface  of  the  right  lobe  of  the  liver  is  affected,  the  enlarge- 
ment is  usually  upward.  If  the  lower  portion  of  the  right  lobe  is 
affected,  enlargement  extends  downward,  and  the  lobe  of  the  liver  can 
readily  be  detected  on  palpation.  The  mass  may  extend  outward  from 
the  liver-edge.  At  first  it  is  hard;  ultimately  it  softens  and  may 
fluctuate.  If  the  abscess  is  limited  to  the  left  lobe  of  the  liver,  and 
is  situated  about  the  suspensory  ligament,  the  enlargement  may  be  seen 
below  the  xiphoid  cartilage  It  may  extend  to  the  umbilicus  and  pro- 
ject forward.  Sometimes  it  may  be  so  large  as  to  cause  eversion  of 
the  ribs  of  each  side,  and  render  the  entire  epigastrium  unusually 
prominent.     The  surface  may  become  reddened.      Over  the  tumor 


648  SPECIAL  DIAGNOSIS. 

there  is  tenderness  on  palpation,  and  there  may  be,  as  in  other  situa- 
tions, fluctuation.     QEdenia  of  the  surface  is  frequently  seen. 

The  irregular  enlargement  above  mentioned  is  made  out  by  percus- 
sion. The  enlargement  may  be  difficult  to  ascertain  ou  account  of 
secondary  pleural  effusion,  or  secondary  pleural  inflammation  with  the 
development  of  a  hepato-pulmonary  fistula,  causing  duluess  poste- 
riorly. If  the  case  has  been  seen  from  the  first,  a  friction-sound  may 
be  heard  followed  by  the  physical  signs  of  effusion. 

The  patient  complains  of  weight  and  fulness  in  the  region  of  the 
liver;  the  enlargement  causes  some  dyspnoea,  and  may  cause  cough 
and  some  vomiting.  The  appetite  is  lost,  and  nausea  at  the  sight  of 
food  is  pronounced.  The  condition  of  the  bowels  may  vary  with  the 
state  of  the  intestinal  tract  at  the  time  of  the  hepatic  complication. 
The  dysenteric  symptoms  may  subside  entirely  or  they  may  continue. 
Often  there  is  constipation,  with  the  passage  of  mucus  and  hardened 
faeces  only.  In  an  obscure  case  the  study  of  the  stools  should  be  made. 
The  detection  of  amoebae  in  the  mucus  or  in  the  intestinal  discharge 
may  point  to  the  true  conclusion. 

Atypical  cases  are  characterized  by  the  absence  of  general  symptoms, 
or  the  absence  of  local  signs.  Fever  may  be  absent  entirely,  exhaus- 
tion alone  beiug  present,  which  could  properly  be  ascribed  to  the  pre- 
vious dysentery.  Pronounced  anaemia  due  to  the  dysentery  may  be 
associated,  as  well  as  inflammation  of  the  joints,  or  neuritis.  In  a 
case  under  my  care  the  only  symptom  for  a  long  time,  with  the  excep- 
tion of  anaemia  and  loss  of  appetite,  was  severe  pain  in  the  sixth  inter- 
space. In  other  instances  there  are  no  liver-symptoms  whatsoever. 
General  symptoms  of  suppuration,  or  an  irregular,  or  even  a  continued 
fever,  the  cause  of  which  cannot  be  ascertained,  may  alone  be  present. 
In  one  of  my  cases  there  was  moderate  continued  fever,  with  loss  of 
appetite  and  dyspeptic  symptoms.  There  was  no  diarrhoea.  No  cause 
could  be  given  for  the  fever,  although  it  was  noted  that  there  was  slight 
enlargement  of  the  liver.  The  patient  slipped  out  of  the  ward  and 
went  down  to  the  yard  to  smoke;  on  his  return  he  was  seized  with  an 
intestinal  hemorrhage  which  could  not  be  checked  and  which  resulted 
fatally.  At  the  autopsy  a  large  abscess  of  the  liver  was  found,  and 
there  was  ulceration  of  the  rectum  from  which  the  intestinal  hemorrhage 
took  place. 

The  diagnosis  is  usually  not  difficult  in  the  typical  cases.  Under  all 
circumstances  attention  must  be  paid  to  the  facts  bearing  upon  the 
aetiology  and  the  association  of  general  and  local  symptoms.  If  the 
general  symptoms  of  suppuration  are  present,  malarial  abscess  may  be 
mistaken  for  an  intermittent  fever.  The  result  of  an  examination  of 
the  blood  and  of  treatment  by  quinine  would  establish  a  diagnosis  of 
malarial  fever.  It  is  difficult  sometimes  to  determine  whether  the 
abscess  is  in  the  abdominal  Avail  or  in  the  liver  proper,  or  whether  it  is 
situated  beneath  the  diaphragm.  If  the  liver  is  movable  with  respira- 
tion, the  two  former  conditions  may  be  excluded.  An  abscess  in  the 
abdominal  wall  is  not  influenced  by  respiration,  and  in  sub-diaphrag- 
matic abscess  the  movement  is  impaired.  Suppuration  of  a  hydatid 
cyst  cannot  be  distinguished  unless  it  has  been  known  beforehand  that 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      649 

a  simple  hydatid  was  present  in  the  liver.  Under  such  circumstances, 
if  suppuration  occurs,  it  is  likely  to  be  confined  to  the  cyst.  Abscess 
of  the  liver  must  be  distinguished  from  gallstones,  attended  by  inter- 
mitting fever  without  suppuration.  While  the  distinction  is  difficult 
in  many  cases,  yet  the  history  of  the  case,  the  association  of  jaundice 
which  deepens  after  each  paroxysm,  and  the  good  general  nutrition  of 
the  patient  point  to  gallstones.  Abscess  of  the  liver  is  of  shorter 
duration  than  cholelithiasis,  and  its  primary  cause  can  usually  be  ascer- 
tained by  examination  of  the  rectum  or  the  discovery  of  suppuration 
in  other  parts  of  the  body. 

Exploratory  puncture  must  be  resorted  to  in  many  cases,  and  it  can 
usually  be  done  with  safety.  Puncture  must  be  made  over  the  region 
in  which  the  enlargement  is  greatest,  or  at  which  the  swelling  is  most 
prominent.  In  abscess  secondary  to  dysentery  a  brownish-colored 
pus  will  be  withdrawn,  resembling  anchovy  sauce.  It  may  be  of  a 
peculiar  odor,  and,  on  examination,  amoebae  common  to  this  form  of 
dysentery  may  be  found.  If  there  is  no  point  of  election,  the  needle 
may  be  introduced  in  the  lowest  interspace  in  the  anterior  axillary,  or 
the  seventh  interspace  in  the  mid-axillary  line.  A  fairly  large-sized 
aspirator  should  be  used.  Suppuration  may  be  present,  and  yet  not  be 
reached  by  aspiration. 

The  complexion  in  tropical  abscess  of  the  liver  is  peculiar,  as  all 
writers  upon  tropical  disease  agree.  The  skin  is  sallow,  the  complexion 
muddy,  the  face  pale.  Through  this  a  slightly  icteroid  tint  may  be 
seen,  and  the  conjunctivas  are  bile-tinged.     Jaundice  is  rare. 

Abscess  of  the  liver  may  also  be  due  to  pyaemia.  It  may  be  a  part 
of  general  pyaemia,  or,  as  previously  mentioned,  of  portal  pyaemia. 
Parasites  and  foreign  bodies,  as  well  as  gallstones,  may  excite  an 
abscess. 

The  echinococcus  cyst  may  suppurate,  or  round-worms  may  pene- 
trate to  the  liver  and  cause  suppuration. 

The  symptoms  of  suppurative  pylephlebitis  and  of  pycemic  abscess  are 
general  and  local.  Jaundice  is  more  common  than  in  solitary  abscess, 
and  there  are  greater  pain  and  tenderness  over  the  liver,  which  is  uni- 
formly enlarged  and  tender.  With  the  enlargement  of  the  liver  and 
jaundice  we  have  the  symptoms  of  pyaemia.  They  are  not  peculiar. 
Sometimes  the  fever  is  distinctly  intermitting,  or  it  may  be  irregular 
and  septic  in  character. 

The  symptoms  of  solitary  abscess  of  the  liver,  as  has  been  previ- 
ously stated,  may  be  obscure,  and  attention  be  called  to  the  liver  only 
when  symptoms  arise  due  to  a  rupture  into  the  neighboring  organs. 
If  perforation  takes  place  into  the  peritoneum,  it  is  not  likely  that  the 
cause  can  be  established  during  life.  The  perforation  frequently  ex- 
tends through  the  diaphragm  to  the  pleura,  and  then  to  the  lung.  An 
empyema  may  be  set  up,  the  true  source  of  which  may  not  be  ascer- 
tained unless  the  pus  is  examined.  The  physical  signs  are  those  of 
empyema — dulness  or  diminished  resonance,  absence  of  fremitus  and 
vocal  resonance,  diminished  breath-sounds,  and  impaired  movement, 
together  with  symptoms-of  cough  and  dyspnoea.  When  the  lung  is 
infected  the  physical  signs  may  resemble  those  of  consolidation.     We 


650  SPECIAL  DIAGNOSIS. 

find  dulness,  bronchial  breathing,  and  increased  tactile  fremitus.  A 
harassing,  convulsive  cough  occurs,  and,  sooner  or  later,  expectoration 
of  a  reddish-brown,  brickdust-colored  material  which  resembles  an- 
chovy sauce.  This  characteristic  expectoration  is  decisive.  It  contains 
arnoebse,  and,  in  addition  to  blood-pigment  and  corpuscles,  orange-red 
crystals  of  hasrnatoidin,  cholesterin-plates,  and  leucin  and  tyrosin. 
When  the  abscess  perforates  into  the  stomach  or  bowel  the  discharge 
from  either  cavity  may  be  of  the  above-mentioned  nature.  Perfora- 
tion into  the  pericardium  is  usually  followed  by  immediate  death. 

Hydatid  Disease  of  the  Liver. 

Hydatid  disease  is  comparatively  rare  in  this  country,  but,  in  my 
own  experience  at  least,  it  is  undoubtedly  increasing  in  frequency. 
Without  any  increase  in  the  opportunities  for  observation,  I  have  seen 
seven  cases  within  the  last  two  years,  compared  to  the  same  number 
during  the  five  previous  years.  The  disease  occurs  in  people  who  live 
with  dogs.  It  may  occur  at  any  age,  but  is  most  common  in  adult 
life.  It  is  very  rare  before  the  fifth,  year.  The  symptoms  are  local, 
depending  upon  the  size  of  the  tumor.  Small  cysts  may  be  present 
without  any  disturbance.  Large  and  growing  cysts  cause  signs  of 
tumor,  with  great  increase  in  the  size  of  the  liver.  The  physical  signs 
depend  upon  the  situation  of  the  tumor.  It  may  be  found  in  the 
median  line  above  the  umbilicus,  causing  a  distinct  prominence,  tense 
and  firm,  which  sometimes  yields  fluctuation.  Quite  often  the  tumor 
grows  at  the  suspensory  ligament,  pushing  the  diaphragm  upward,  dis- 
locating the  heart,  and  causing  an  increased  area  of  dulness  in  the  left 
upper  quadrant.  In  this  position  it  may  simulate  a  pancreatic  cyst  or 
effusion  in  the  lesser  peritoneal  cavity.  If  the  tumor  is  in  the  right 
lobe,  the  enlargement  of  the  liver  may  be  upward  or  downward.  The 
upper  border  of  liver-dulness  may  begin  two  or  three  interspaces  higher 
than  normal  posteriorly  or  in  the  axillary  region.  If  the  cysts  are 
superficial,  when  palpated  with  the  fingers  of  the  left  hand  and  per- 
cussed with  the  right  a  vibration  or  trembling  movement  is  felt,  which 
may  continue  for  a  certain  time.  It  is  known  as  the  hydatid  fremitus. 
It  is  not  always  present.  The  enlargement  is  painless.  Local  sensa- 
tions of  weight  and  dragging  may  be  complained  of.  If  suppuration 
sets  in,  there  may  be  a  good  deal  of  pain. 

The  general  symptoms  are  negative;  the  nutrition  does  not  suffer 
unless  the  enlarged  mass  interferes,  by  its  pressure,  with  physiological 
acts  of  digestion  and  assimilation.  If  suppuration  sets  in,  the  general 
symptoms  of  abscess  of  the  liver  arise.  Jaundice  is  more  common 
than  in  tropical  abscess.  The  abscess  may  perforate  into  one  of  the 
adjacent  hollow  viscera,  or  into  the  pleura  and  bronchi.  It  may  per- 
forate externally.  It  may  perforate  into  the  pericardium  or  vena  cava, 
and  cause  death.  If  perforation  takes  place  in  the  biliary  passages, 
obstructive  jaundice  arises,  with  secondary  suppurative  cholangitis. 
When  the  cysts  rupture,  or  if  they  are  aspirated,  an  eruption  of  urti- 
caria may  break  out.  This  is  not  of  diagnostic  significance,  except  that 
it  may  point  to  rupture  of  the  cyst. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      651 

Diagnosis.  The  diagnosis  is  not  difficult.  The  occurrence  of  irreg- 
ular, painless  enlargement  of  the  liver  without  general  symptoms^  is 
significant.  If  fluctuation  is  detected,  or  the  fremitus,  a  more  positive 
conclusion  can  be  reached.  When  suppuration  takes  place  the  symp- 
toms are  like  those  of  abscess  of  the  liver.     Hydatid  disease  is  to  be 


Human  echinococci.    (From  Finlayson,  after  Davaine.) 

A,  a  group  of  echinococci,  still  adhering  to  the  germinal  membrane  by  their  pedicles.  X  40. 

B,  an  echinococcus  with  head  invaginated  in  the  body.    X  107. 

C,  the  same  compressed,  showing  the  suckers  and  hooks  of  the  retracted  head. 

D,  echinococcus  with  head  protruded. 

E,  crown  of  hooks,  showing  the  two  circles.    X  350. 

distinguished  from  syphilitic  hepatitis,  in  which  the  enlargement  is  hard 
and  irregular,  and  does  not  fluctuate.  Sometimes  the  symptoms  resem- 
ble cancer,  but  the  age  of  the  patient,  the  presence  of  jaundice,  and 
the  extreme  emaciation  and  cachexia  indicate  that  affection  rather  than 
hydatid  disease.     Enlargement  of  the  gall-bladder  containing  a  mucoid 

Fig.  116. 


■^ 


ijf       f 


^^ 


^=^> 


Hooks  from  taenia  echinococcus.    X  350. 


fluid,  in  which  fluctuation  can  be  detected,  may  simulate  hydatid  dis- 
ease. The  enlargement,  however,  may  be  preceded  by  conditions  which 
cause  obstruction  of  the  cystic  duct.  The  gall-bladder  is  movable.  In 
some  instauces  there  may  be  resonance  between  it  and  the  liver.  It  is 
usually  of  a  pyriform.or  oblong  shape.  In  hydronephrosis  the  symp- 
toms of  a  localized  cyst  are  present.     It  does  not  move  with  respira- 


652  SPECIAL  DIAGNOSIS. 

tion,  as  in  hydatid  disease;  it  is  attended  by  symptoms  of  renal  disease; 
exploratory  puncture  is  sometimes  necessary  to  establish  a  diagnosis.  A 
hydatid  cyst  is  frequently  confounded  with  pleural  effusion  of  the  right 
side,  for  there  may  be  all  the  physical  signs  of  effusion  at  the  right 
base.  The  distinction  can  be  made  by  the  character  of  the  line  of  dul- 
ness.  In  hydatid  cyst,  as  Frerichs  points  out,  it  is  a  curved  line,  the 
greatest  height  of  which  is  found  in  the  scapular  region.  It  is  not  diffi- 
cult usually  to  distinguish  hydatid  cyst  from  other  forms  of  painless 
enlargement.  In  fatty  and  amyloid  disease  the  enlargement  is  uni- 
form. Both  are  of  common  occurrence  in  individuals  of  previous  ill 
health,  whereas  hydatid  disease  occurs  in  healthy  individuals. 

An  absolute  diagnosis  of  hydatid  disease  is  based  upon  the  results 
.  of  exploratory  puncture.  When  this  is  made  over  a  tumor,  or  the 
centre  of  duluess,  if  it  is  due  to  hydatid  disease,  a  clear  fluid,  slightly 
opalescent,  is  withdrawn.  The  fluid  is  of  a  specific  gravity  of  1005  to 
1009;  it  is  of  neutral  reaction,  does  not  contain  albumin,  but  con- 
tains chlorides  and  sometimes  traces  of  sugar.  Hooklets  may  be  found 
in  the  clear  fluid. 

Diseases  of  the  Gall-ducts. 

_  Catarrhal  Jaundice.  This  is  due  to  inflammation  and  obstruc- 
tion of  the  terminal  portions  of  the  common  bile-duct.  But  few  words 
are  necessary,  as  it  has  been  referred  to  frequently  in  speaking  of  jaun- 
dice. The  symptoms  are  those  of  moderate  jaundice,  occurring  coin- 
cidently  with  or  following  in  a  few  days  upon  an  attack  of  acute 
gastritis.  The  disease  may  occur  in  epidemic  form.  The  onset  is 
more  severe,  attended  by  chill  and  fever,  with  headache  and  vomiting. 
The  temperature  does  not  go  beyond  102°.  In  addition  the  signs  of 
obstructive  jaundice  are  present.  The  liver  is  normal  in  size  or  slightly 
enlarged  and  tender.  The  jaundice  continues  from  four  to  eight  weeks, 
but  may  disappear  in  a  shorter  time.  The  first  sign  of  relief  is  a 
change  in  the  appearance  of  the  stools.  The  clay-colored  stools  dis- 
appear and  the  normal  color  returns.  The  affection,  especially  the 
epidemic  form,  usually  occurs  in  young  subjects. 

The  diagnosis  is  based  upon  the  age,  the  association  of  the  jaundice 
with  gastritis,  for  which  a  definite  cause  can  often  be  assigned;  the 
absence  of  organic  heart  disease,  or  any  lesion  within  the  "body,  on 
account  of  which  jaundice  might  arise;  the  moderate  degree  of  jaun- 
dice, the  absence  of  emaciatiou  and  symptoms  of  portal  obstruction, 
the  occurrence  of  moderate  enlargement  without  pain.  It  must  not 
be  forgotten  that  jaundice  due  to  obstruction  from  gallstones,  or  to 
pressure  from  tumors  outside  of  the  duct,  is  characterized  in  its  onset 
by  symptoms  similar  to  those  just  mentioned.  It  is  often  necessary  to 
wait  before  giving  an  opinion;  a  history  of  previous  attacks  of  jaun- 
dice and  the  age  of  the  patient,  over  forty  years,  also  lead  to  caution 
in  the  diagnosis. 

Gallstones.  Gallstones  form  in  the  biliary  passages  and  may 
remain  there  without  creating  symptoms,  or  they  may,  by  the  efforts 
to  pass  them,   cause  attacks  of  pain  called  hepatie  or  biliary  colic, 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       653 

after  which  the  stone  may  pass  into  the  iutestiual  tract  without  further 
hepatic  symptoms.  It  may  become  impacted  in  the  biliary  canal 
and  set  up  catarrhal  or  suppurative  inflammation,  which  in  turn  may 
be  followed  by  stricture.  Gallstones  usually  form  or  at  least  show 
signs  of  their  presence  after  the  age  of  forty  years,  most  frequently  in 
women  and  in  people  who  have  led  a  sedentary  life  and  partaken  of 
rich  and  indigestible  food.  Individuals  in  different  generations  of 
the  same  family  may  be  predisposed  to  them. 

Hepatic  Colic.  The  passage  of  gallstones  may  be  attended  by 
a  slight  amount  of  pain  only,  which,  unless  in  the  right  upper  quad- 
rant, would  pass  for  an  attack  of  simple  indigestion.  In  the  large 
majority  of  cases  the  pain  is  severe.  The  attack  may  be  preceded  by 
biliousness  or  indigestion  for  twenty-four  hours,  and  moderate  pains 
or  a  sense  of  weight  and  fulness  in  the  liver.  It  frequently  follows 
the  taking  of  food.  Ringing  in  the  ears,  disturbance  of  vision,  or 
undue  flushings  are  said  to  precede  it  in  some  instances. 

The  attack  may  be  sudden.  The  patient  is  seized  with  pain  along 
the  margin  of  the  ribs  of  the  right  side,  or  there  may  be  pain  above 
the  ribs,  over  the  liver,  and  in  the  right  shoulder  at  the  same  time. 
From  the  hepatic  region  it  extends  to  the  median  line.  Very  fre- 
quently the  pain  begins  and  continues  in  the  epigastrium.  It  may  be 
most  pronounced  in  this  locality  from  the  first.  The  pain  is  intense  and 
paroxysmal.  The  patient  is  doubled  up  in  agony.  It  causes  more  or 
less  collapse.  The  pulse  increases.  Vomiting  usually  occurs  at  the 
same  time,  consisting  first  of  the  contents  of  the  stomach,  and  then  of 
a  yellowish,  bile-stained  fluid.  The  vomiting  may  be  extreme,  so  that 
the  patient  is  tormented  by  the  pain,  th^  retching,  and  vomiting.  The 
attack  sometimes  disappears  as  suddenly  as  it  occurred,  or  Avears  off 
gradually.  When  most  severe,  symptoms  of  shock  follow.  The  bowels 
are  not  disturbed  during  the  attack.  The  urine  may  become  sup- 
pressed; it  is  high-colored.     After  the  attack  it  may  contain  bile. 

At  the  time  of  the  attack  there  is  considerable  tenderness  below  the 
xiphoid  cartilage  and  in  the  hepatic  region.  The  tenderness  is  more 
marked  on  deep  pressure  in  the  gall-bladder  region  and  to  the  right  of 
the  mid-clavicular  line,  at  the  margin  of  the  ribs.  The  epigastrium 
may  be  slightly  swollen.  The  tenderness  persists  after  the  attack,  and 
the  stomach  may  be  weak  or  irritable  for  some  time;  pain,  however, 
usually  disappears  at  once.  The  attack  may  recur  frequently  until  the 
stone  has  been  passed,  so  that  in  twenty-four  hours  the  patient  may 
have  a  dozen  or  more  paroxysms.  After  the  attacks  have  subsided 
light  jaundice  may  supervene,  which  usually  does  not  continue  niore 
than  a  Aveek  at  the  furthest,  and  during  which  there  are  also  symptoms 
of  mild  gastritis.     (See  Intestinal  Colic.) 

In  some  instances  a  chill  precedes  or  immediately  follows  the  pain, 
after  which  the  temperature  rises.  After  the  paroxysm  subsides  the 
fever  disappears  rapidly,  being  followed  by  profuse  perspiration.  If 
the  gallstones  have  set  up  catarrhal  inflammation,  moderate  fever 
may  continue  for  a  few  days.     (See  Fever  in  Obstruction.) 

During  any  paroxysm  of  hepatic  colic  it  is  desirable  to  determine 
whether  or  not  a  gallstone  has  been  passed.     This  can  only  be  done 


654  SPECIAL  DIAGNOSIS. 

by  placing  the  faeces  in  a  sieve  and  pouring  water  upon  them  until  they 
dissolve.  Instead  of  gallstones,  dark-colored  granular  bile,  which 
has  become  inspissated,  is  sometimes  seen  in  the  movements.  Bile  in 
this  form  gives  rise  to  as  much  pain,  according  to  Harley,  as  true  bil- 
iary concretions.  If  the  stone  is  not  passed,  it  may  fall  back  into  the 
gall-bladder  and  cause  no  further  symptoms  for  a  time,  or  become 
impacted  in  the  ducts.  The  impaction  may  be  such  that  no  obstruc- 
tion is  caused  by  its  position,  the  bile  being  forced  through  or  around 
it;  or  complete  obstruction  may  take  place.      (See  Jaundice.) 

Obstruction  of  the  Ducts.  The  symptoms  from  obstruction 
depend  upon  its  seat.  If  the  obstruction  is  in  the  cystic  duct,  there  is 
enlargement  of  the  gall-bladder.  The  liver  is  not  secondarily  affected. 
The  enlargement  is  noted  at  the  edge  of  the  liver  in  the  usual  situation, 
and  may  gradually  increase  to  an  enormous  extent,  so  that  it  has  been 
mistaken  for  an  ovarian  cyst.  The  gall-bladder  is  often  quite  movable, 
and  on  account  of  its  location  and  movability,  as  well  as  its  long  shape, 
has  been  mistaken  for  a  floating  or  movable  kidney.  If  the  gall-bladder 
is  not  too  large,  it  can  be  felt  as  a  rounded  or  pyriform  mass  when 
the  hand  is  placed  along  the  margin  of  the  liver,  becoming  more  marked 
when  the  patient  takes  a  full  breath.  The  enlargement  is  not  attended 
by  any  other  symptoms  except  mechanical  ones,  unless  the  contents 
of  the  gall-bladder  are  purulent.  In  obstruction  with  simple  enlarge- 
ment the  fluid  of  the  gall-bladder,  should  aspiration  be  performed,  is 
thin,  of  a  mucoid  nature,  and  alkaline  in  reaction.  It  may  contain 
cholesterin-plates,  and  sometimes  blood.  It  must  be  distinguished 
from  the  fluid  of  a  hydatid  cyst. 

Simple  enlargement  of  the  gall-bladder  must  be  distinguished  from 
enlargements  due  to  inflammation.  (1)  Acute  phlegmonous  inflamma- 
tion of  the  gall-bladder  may  take  place  attended  by  localized  pain  and 
tenderness,  by  high  temperature,  extreme  prostration,  and  the  rapid 
development  of  the  typhoid  state.  Peritonitis  rapidly  ensues.  It 
cannot  be  distinguished  from  other  forms  of  acute  inflammation  in  the 
same  region,  unless  there  was  (a)  a  history  of  gallstones;  (6)  tumor 
of  the  gall-bladder  before  the  attack  developed.  (2)  Suppurative 
inflammation  of  the  gall-bladder  may  occur  from  gallstones  and  in  in- 
fectious diseases.  The  enlargement  may  increase,  the  tumor  becoming 
tender  and  painful  on  palpation.  The  direction  of  growth  is  toward 
the  umbilicus.  The  general  symptoms  are  those  of  suppuration. 
Hectic  fever  or  markedly  remittent  fever  occurs,  and,  unless  surgical 
relief  is  given,  peritonitis  ensues  from  infection  or  from  rupture. 
This  complication  may  be  suspected  from  the  occurrence  of  collapse 
and  increase  of  the  local  symptoms. 

Tumors  of  the  gall-bladder,  usually  due  to  cystic  obstruction,  as  pre- 
viously mentioned,  may  be  mistaken  for  floating  kidney,  for  tumor  of 
the  pylorus,  and  for  ovarian  cyst. 

Tumors  of  the  gall-bladder  from  any  of  the  above-mentioned  causes 
are  recognized  by  their  position  and  shape,  and  by  the  character  of  the 
tumor.  The  position  varies.  The  usual  site  is  in  the  gall-bladder 
region,  but  it  may  extend  as  low  as  the  groin,  or  may  be  so  large  as 
to  distend  the  ribs  and  fill  almost  the  entire  abdominal  cavity.     If, 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       655 

however,  the  case  has  been  under  observation  from  the  beginning,  the 
tumor  must  have  been  found  originally  in  the  gall-bladder  region. 
This  region  corresponds  to  the  poiut  of  intersection  of  the  border  of 
the  ribs  by  a  line  drawn  from  the  acromion  process  of  the  right  shoul- 
der to  the  umbilicus.  The  tumor  grows  from  this  point  toward  the 
umbilicus  iu  nearly  all  the  cases.  It  can  be  recognized  by  its  shape, 
which  is  pyriform  or  globular.  The  character  of  the  tumor  varies.  It 
is  usually  tender,  firm,  but  elastic  on  pressure  and  movable.  Fluctua- 
tion may  ofteu  be  detected.  If  the  enlarged  gall-bladder  contains  calculi, 
they  may  be  felt  as  small,  hard  masses  which  cause  a  grating  sensation 
to  be  transmitted  to  the  finger.  On  aspiration,  if  the  cystic  duct  is  ob- 
structed, the  mucoid  fluid  previously  mentioned,  or  pus,  is  withdrawn. 
If  the  common  duct  is  obstructed,  bile  will  pass  through  the  trocar. 

The  enlargement  must  be  distinguished  from  tumors  of  the  liver, 
stomach,  duodenum,  paucreas,  or  lymphatic  glands.  Tumors  of  the 
liver  are  usually  due  to  carcinoma.  They  are  multiple,  associated 
with  enlargement  of  the  liver,  with  jaundice,  ascites,  enlargement  of 
the  spleen,  and  emaciation.  Tumors  of  the  stomach,  duodenum,  and 
pancreas  are  in  a  different  position,  and  are  attended  by  functional 
disturbance  of  the  respective  organs  from  which  they  spring.  An 
abscess  of  the  liver,  if  purulent,  may  simulate  enlargement  of  the 
gall-bladder.  If  the  abscess  can  be  palpated,  an  area  of  induration  is 
first  felt,  followed  afterward  by  softening  and  fluctuation  of  the  swell- 
ing. In  judging  of  the  true  nature  of  the  tumor  we  must  bear  in 
mind  the  causes  of  abscess.  In  hydatid  disease  the  tumor  develops 
slowly;  it  is  painless;  it  may  yield  fremitus,  and,  if  movable,  the 
course  is  slow  and  not  attended  by  general  symptoms.  Multilocular 
hydatid  disease  can  rarely  be  distinguished  save  by  the  difference  in 
position  of  the  tumor.  It  is  nodulated,  hard,  and  tender,  but  is  asso- 
ciated with  jaundice,  ascites,  oedema  of  the  legs,  enlarged  spleen,  and 
great  emaciation  and  prostration,  with  rapid  decline.  A  syphilitic 
gumma  in  the  liver  may  occupy  the  region  of  the  gall-bladder.  It  can 
usually  be  made  out  as  continuous  with  the  liver-structure.  It  is  ten- 
der and  painful,  but  irregular;  other  signs  of  syphilis,  or  a  history 
of  the  infection  and  of  symptoms  of  a  primary  and  secondary  period 
will  aid  in  the  distinction  of  the  disease. 

Floating  Kidney.  The  gall-bladder  is  larger  and  fixed  at  one  end, 
whereas  the  entire  kidney  is  movable.  The  gall-bladder  may  fluctuate 
and  is  associated  with  symptoms  of  hepatic  disease.  On  the  other 
hand,  the  well-known  symptoms  of  floating  kidney,  the  shape  of  the 
tumor,  the  sensation  of  nausea  induced  by  palpation,  point  to  the 
renal  origin  of  the  mass.  Tumors  of  the  kidney  must  be  distinguished, 
such  as  sarcoma,  hydronephrosis,  and  pyonephrosis.  1.  There  may 
be  changes  in  the  urine.  2.  In  renal  tumors  the  intestine  is  in  front 
of  some  portion  of  them,  or  a  zone  of  resonance  is  found  between  the 
liver-dulness  and  the  tumor.  3.  Renal  tumors  are  fixed.  They  may, 
as  in  hydronephrosis,  come  and  go,  preceded  by  attacks  of  renal  colic 
and  attended  by  anuria.  From  ovarian  or  uterine  tumors  the  diagnosis 
must  be  made  by  examination  of  the  genital  organs,  although  with 
the  former  there  is  often  difficulty. 


656  SPECIAL  DIAGNOSIS. 

Enlargement  of  the  gall-bladder  on  account  of  calculous  obstruc- 
tion must  be  distinguished  from  enlargement  due  to  cancer  of  that 
organ.  This  is  often  difficult  and  cannot  be  done  without  having  the 
patient  under  observation  for  a  long  period  of  time.  Cancer  of  the 
gall-bladder  is  usually  primary.  It  may  begin  in  the  gall-ducts.  In  the 
larger  number  of  cases  it  occurs  in  patients  who  have  had  gallstones. 
It  is  found  most  frequently  in  females,  and  after  the  fiftieth  year. 
Tight-lacing  or  pressure  around  the  abdomen  may  predispose  to  it. 
The  symptoms  are  pain,  jaundice,  emaciation,  cachexia,  and  the  pres- 
ence of  a  tumor.  The  pain  is  localized  and  lancinating  in  character. 
Jaundice  occurs  in  70  per  cent,  of  the  cases,  and  gradually  increases 
in  intensity.  The  tumor  is  situated  in  the  gall-bladder  region,  to  the 
right  of  the  umbilicus  It  is  hard  or  firm,  painful,  and  the  seat  of 
tenderness.  The  tumor  is  fixed.  Sometimes  the  disease  is  found  in 
the  cystic  duct,  and  then  the  gall-bladder  is  enlarged.  As  the  history 
of  gallstones  is  of  frequent  occurrence  in  both  instances,  it  is  impos- 
sible to  distinguish  the  two  forms  of  obstruction  causing  enlargement, 
save  that  in  carcinoma  the  emaciation  and  cachexia  may  point  to  the 
true  nature  of  the  case.  In  tumor  of  the  gall-bladder  due  to  cancer 
the  secondary  effects  on  the  liver  are  usually  more  marked  than  in 
tumor  from  other  causes.  The  liver  enlarges  and  its  surface  becomes 
irregular  or  nodular.1 

Symptoms  of  Forms  of  Stenosis.  In  stenosis  of  the  bile-ducts  the  chief 
symptom  is  jaundice.  Colicky  pains  occurring  in  paroxysms,  inter- 
mittent jaundice  varying  in  intensity,  and  an  intermittent  fever,  point 
to  gallstones.  If  the  obstruction  is  due  to  disease  outside  of  the  ducts, 
its  nature  must  be  inferred  from  the  symptoms  and  physical  signs  of 
disease  in  neighboring  structures.  If  the  jaundice  is  due  to  enlarge- 
ment of  the  lymphatic  glands,  its  nature  may  be  inferred  from  the 
presence  of  primary  carcinoma  in  other  organs  of  the  body,  or  from 
the  condition  of  the  lymphatic  glands  in  other  parts.  If  they  are  the 
seat  of  malignant  disease,  it  can  usually  be  recognized.  In  the  case  of 
Hodgkin's  disease  the  examination  of  the  blood  may  be  of  service  in 
the  diagnosis.,  Cancer  of  the  liver  must  be  excluded  by  its  symptoms 
— enlargement  with  jaundice,  with  moderate  fever,  rapid  emaciation, 
and  short  duration  of  the  disease.  Cancer  of  the  panaceas  is  a  very 
common  cause  of  stenosis. 

Obstruction  of  the  Common  Duct  by  Gallstones,  (a)  In  addition  to 
jaundice  paroxysms  of  chill,  fever,  and  sweat  occur,  with  catarrhal 
inflammation  of  the  biliary  passages.  (1)  The  paroxysms  resemble 
intermittent  fever;  (2)  the  jaundice  may  continue  for  years  and  deepen 
after  each  paroxysm;  (3)  hepatic  colic  may  occur  with  the  paroxysm; 
(4)  health  fails  but  slightly.  The  paroxysms  may  occur  daily  or  only 
once  a  week,  or  they  may  be  tertian  and  quartan  in  type.  The  pain 
is  referred  to  other  situations  than  the  gall-bladder  or  the  epigastrium. 
It  is  often  relieved  by  vomiting  or  by  certain  positions  of  the  body. 
The  jaundice  may  be  intermittent  or  remittent.  On  account  of  the 
obstruction  in  this  situation  the  liver  becomes  enlarged.     It  is  firm 

i  See  Musser :  Trans.  Assoc.  Amer.  Physicians,  vol.  iv.,  1889. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       657 

and  smooth  on  palpation.  The  gall-bladder  is  not  enlarged.  The 
enlargement,  as  determined  by  percussion,  is  uniform.  Fenger's 
thorough  studies  show  that  the  intermittent  phenomena  are  due  to  the 
ball-valve  action  of  a  single  stone.  He  also  points  out  that  emaciation 
is  of  common  occurrence.  (6)  Gallstones  may  cause  suppurative  in- 
flammation of  the  biliary  ducts,  just  as  suppuration  of  the  gall-bladder 
may  ensue.  The  symptoms,  both  general  and  local,  are  pronounced. 
The  fever  may  be  intermittent,  but  is  more  likely  to  be  remittent; 
jaundice  is  present,  but  it  is  constant  in  its  intensity.  The  local  signs 
of  enlargement  and  tenderness  are  made  out.  The  patients  die  of 
exhaustion  or  septicaemia.  Sometimes  the  gall-bladder  ruptures  into  the 
stomach  or  colon,  and  temporary  abeyance  of  the  symptoms  may  result. 
The  Accidents  of  Gallstones.  While  these  effects  of  the  presence  of 
stones  in  the  biliary  passages  may  rightly  be  considered  as  accidents, 
nevertheless  their  occurrence  is  so  common  as  to  be  part  and  parcel  of 
the  history  of  gallstones.  As  accidents,  we  have  most  commonly  the 
occurrence  of  localized  peritonitis  which  leads  to  dislocation  of  the 
gall-bladder,  constriction  of  the  duodenum  with  secondary  dilatation 
of  the  stomach;  we  also  have  the  formation  of  biliary  fistula,  with 
passage  of  the  gallstone  into  the  contiguous  organs  or  channels.  The 
stone  may  ulcerate  into  the  gall-bladder  from  one  of  the  ducts,  may 
perforate  the  portal  vein,  or  may  perforate  into  the  abdominal  cavity 
— the  most  frequent  accident.  Perforation  also  takes  place  into  the 
duodenum,  into  the  colon,  and,  rarely,  into  the  stomach.  Such  per- 
foration can  only  be  inferred  from  its  secondary  effects  :  (1)  An  attack 
of  gallstones;  (2)  local  inflammation  with  fever;  (3)  the  occurrence 
of  peritonitis,  or  the  discharge  of  pus  by  the  bowels,  or  by  vomiting. 
That  it  is  due  to  gallstones  is  proved  in  those  rare  instances  in  which 
the  stone  is  passed  per  rectum.  Often  it  may  be  impacted  in  the  intes- 
tinal canal,  causing  symptoms  of  acute  obstruction,  or  in  the  rectum, 
causing  local  tormina  and  tenesmus.  The  perforation,  however,  occurs 
in  other  directions.  Sometimes  fistulous  connection  is  formed  between 
the  gall-bladder  and  the  urinary  passages,  calculi  and  pus  being  dis- 
charged iu  the  urine.  In  other  instances  fistulse  between  the  bile-pas- 
sages and  the  lungs  take  place.  The  bile  is  coughed  up  and  expec- 
torated, sometimes  with  small  calculi.  In  the  most  common  form 
ulceration  proceeds  toward  the  surface,  with  formation  of  cutaneous 
fistula.  After  the  fistula  has  opened  externally  gallstones  in  large 
numbers  may  be  passed.  If  not,  the  cause  of  the  fistula  must  be 
determined  by  the  history  and  the  results  of  investigation  by  probe, 
due  attention  being  given  to  the  condition  of  other  organs. 

Diseases  of  the   Spleen. 

Palpation  and  Percussion  of  the  Spleen.  The  spleen  lies  in 
the  left  upper  quadrant  beneath,  and  in  contact  with  the  diaphragm 
above,  and  below  with  the  tail  of  the  pancreas,  cardiac  end  of  the 
stomach,  and  suprarenal  capsule.  It  extends  transversely  between 
the  upper  border  of  the  ninth  rib  and  the  lower  border  of  the  eleventh 
rib,  and  from  the  middle  axillary  line  posteriorly  toward  the  spine. 

42 


658  SPECIAL  DIAGNOSIS. 

An  enlarged  spleen  usually  retains  the  normal  shape.  The  direc- 
tion of  the  enlargement  is  downward  and  inward.  It  is  accessi- 
ble to  palpation  in  proportion  to  the  degree  of  enlargement  and  of 
relaxation  of  the  abdominal  walls.  It  is  movable  with  respiration. 
It  cannot  be  said  to  be  enlarged  unless  the  edge  is  palpable  at  the  end 
of  deep  inspiration,  notwithstanding  there  may  be  increased  dulness 
in  the  lower  axillary  region.  When  moderately  enlarged,  the  smooth, 
blunt,  rounded  anterior  surface  and  sharp  edge  of  the  spleen  can  be 
felt  at  the  margin  of  the  ribs,  in  deep  inspiration;  when  the  enlarge- 
ment is  great,  as  in  leukaemia,  the  organ  can  be  grasped  with  both 
hands,  and  its  hilus  clearly  mapped  out.  The  same  thing  can  be  done 
in  the  rare  instances  of  floating  spleen,  but  here  a  knee-chest  position 
will  favor  successful  palpation.  The  posterior  border  of  an  enlarged 
spleen  can  usually  be  made  out  by  passing  the  hand  backward  over 
the  resisting  organ.  At  its  posterior  border  a  non-resisting  space  can 
be  detected  between  the  border  and  the  mass  of  lumbar  muscle.  In 
children  it  is  always  easy  to  define  this  border.  JSTo  such  space  exists 
in  renal  enlargements.  The  existence  of  this  space  and  the  direction  of 
enlargement  of  the  spleen  are  due  to  the  costo-colic  fold  of  peritoneum 
(Jenner).  In  splenic  leukaemia  the  spleen  may  be  larger  after  a  meal, 
yield  a  creaking  fremitus  on  palpation,  a  murmur  on  auscultation,  and 
may  even  pulsate.  The  spleen  may  also  lessen  in  size  after  diarrhoea 
or  free  hemorrhage.  As  it  lies  entirely  behind  the  ribs,  it  does  not,  of 
course,  admit  of  palpation  when  the  size  is  normal. 

Percussion.  Being  a  solid  body  it  gives  a  dull  sound  on  percus- 
sion, contrasting  with  pulmonary  resonance  above,  intestinal  tympany 
below,  and  stomach  tympany  anteriorly.  Posteriorly  and  below  its 
dulness  merges  into  that  of  the  lumbar  region  and  kidney.  The  upper 
posterior  portion  is  hidden  behind  the  diaphragm  and  overlapping  lung, 
and  hence  is  not  accessible  to  percussion.  Practically,  therefore,  the 
normal  splenic  dulness  extends  between  the  ninth  and  eleventh  ribs, 
in  the  middle  and  posterior  axillary  lines,  the  spleen  being  there  in 
contact  with  the  ribs. 

In  percussion  of  the  spleen  the  patient  should  lie  on  his  right  side. 
Beginning  from  above  downward  we  percuss  gently  until  pulmonary 
resonance  is  succeeded  by  dulness  ;  then  anteriorly  proceeding  toward 
the  axilla,  until  stomach  tympany  yields  to  dulness.  In  the  same  way, 
percussing  from  below  upward,  the  line  is  reached  where  intestinal 
tympany  gives  way  to  dulness. 

The  spleen  may  be  compressed  by  the  stomach  or  colon  distended  with 
gas,  and  its  dulness  may  appear  increased  through  distention  of  the 
stomach  and  colon  with  solid  matter,  or  by  a  left  pleural  effusion,  or  left 
basal  pneumonia.  The  spleen  may  also  be  pressed  upward  by  ascites  or 
by  a  large  abdominal  tumor,  so  that  its  normal  dulness  is  much  lessened. 

If  the  ligament  which  holds  it  in  place  becomes  relaxed,  the  spleen 
may  become  floating.  According  to  Stintzing,  a  floating  spleen  is 
increased  in  density,  is  generally  enlarged,  and  is  recognized  by  its 
form  (notch,  etc.),  by  being  movable  to  and  fro,  and  by  the  absence 
of  splenic  dulness  in  the  normal  position,  and  its  reappearance  when 
the  spleen  is  replaced. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      659 

Enlargement  of  the  spleen  may  be  acute  or  chronic.  Acute  enlarge- 
ment occurs  in  certain  infectious  diseases,  particularly  typhoid  fever, 
typhus,  smallpox,  relapsing  fever,  scarlet  fever,  diphtheria,  epidemic 
cerebro-spinal  meningitis,  the  malarial  fevers  and  meningitis,  and  in 
diseases  with  blood-poisoning,  as  septicaemia,  puerperal  fever,  and 
erysipelas. 

A  rare  cause  of  enlargement  is  acute  splenitis.  Generally  it  is  the 
result  of  emboli  lodged  in  the  spleen  and  starting  from  an  endocarditis. 
The  area  of  splenic  dulness  extends  rapidly,  and  there  are  local  pain 
and  tenderness  on  pressure,  increased  by  coughing  and  deep  inspira- 
tion; other  symptoms  are  fever,  nausea  and  vomiting,  and  occasionally 
delirium.  If,  as  frequently  happens  in  splenitis,  emboli  lodge  in  the 
kidneys  also,  the  urine  will  be  albuminous  and  bloody.  If  suppu- 
ration ensues,  the  fever  becomes  hectic,  and  the  spleen  continues  to 
increase  in  size.  Splenic  abscess  may,  however,  remain  latent  until 
rupture  occurs. 

Enlargement  of  the  spleen  can  be  distinguished  from  enlargement 
of  the  left  kidney  by  the  greater  movability  of  the  spleen.  1.  The 
spleen  does  not  extend  as  far  back  toward  the  spine  as  the  kidney,  so 
that  the  fingers  can  be  thrust  behind  its  posterior  border,  and,  if  the 
other  hand  grasp  the  anterior  edge,  the  organ  can  be  moved  backward 
and  forward.  Splenic  dulness  extends  to  the  ninth  rib  or  higher. 
Kidney-dulness  has  no  thoracic  area,  but  reaches  to  the  spine  (lum- 
bar). 2.  Again,  the  spleen  is  more  movable  with  respiration  than 
the  kidney  is.  3.  The  spleen  falls  further  toward  the  median  line, 
when  the  patient  is  in  the  knee-chest  position,  than  does  the  kidney. 
4.  An  enlarged  kidney  has  the  colon  in  front  of  it,  and  hence  its  dul- 
ness is  obscured  by  the  tympany  of  the  bowel.  5.  The  shape  of  an 
enlarged  kidney  is  more  globular  than  that  of  the  spleen.  The  ante- 
rior surface  of  the  latter  is  smooth  and  rounded,  but  at  its  junction 
with  the  flat  posterior  surface  there  is  a  sharp  edge.  6.  Pain  in  renal 
diseases  often  shoots  down  the  ureters  and  into  the  testicles.  In  dis- 
eases of  the  spleen  the  pain  is  generally  localized  to  the  splenic  region, 
and  may  shoot  into  the  left  shoulder.  7.  Result  of  examination  of 
the  urine  will  often  make  clear  that  the  disease  is  renal,  or,  by  its  neg- 
ative result,  will  point  to  the  splenic  origin  of  the  tumor. 

It  is  sometimes  difficult  to  demonstrate  enlargement  of  the  spleen 
when  the  liver,  and  particularly  the  left  lobe,  are  enlarged.  Careful 
palpation  reveals  the  edge  of  the  spleen,  which  descends  further  than 
the  liver  in  full  inspiration.  Having  found  the  anterior  edge,  pressure 
with  the  other  hand  posteriorly  will  bring  the  spleen  forward,  which 
would  not  occur  if  the  suspected  enlargement  was  the  left  lobe  of  the 
liver. 

Chronic  enlargement  of  the  spleen  occurs  as  hypertrophy  and  as  the 
result  of  amyloid  disease,  leukaemia  and  pseudo-leukaemia,  chronic 
malarial  poisoning  (ague-cake),  syphilis,  hydatid  tumor,  and  cancer. 
Enlargement  is  greatest  in  leukaemia  and  in  ague-cake.  The  spleen  in 
well-marked  cases  of  these  affections  may  reach  to  the  umbilicus  and 
even  beyond,  filling  up  the  hypogastrium  and  extending  to  the  right 


660  SPECIAL  DIAGNOSIS. 

iliac  region,  measuring  thirteen  or  fourteen  inches  in  length  and  half 
as  much  in  breadth,  and  proportionately  increased  in  thickness. 

Diagnosis  of  Enlargement  of  the  Spleen.  The  diagnosis 
of  splenic  leukcemia  rests  principally  upon  the  blood-condition,  particu- 
larly upon  the  existence  of  a  marked  increase  of  white  blood-cells. 
Red  cells  are  decreased,  and  altered  forms  are  present.  In  addition  to 
characteristic  blood-changes  there  is  a  great  disposition  to  hemorrhages ; 
dropsies  and  priapism  are  common;  and,  in  later  stages,  fever,  diar- 
rhoea, great  weakness,  and  grave  complications,  such  as  pneumonia. 

Hemorrhage  in  splenic  leukaemia  occurs  from  the  nose,  bowel,  stom- 
ach, gums,  or  kidney.  It  may  also  be  subcutaneous,  intermuscular, 
cerebral,  or  retinal. 

Regarding  the  diagnosis  of  splenic  hypertrophy  (ague-cake)  in  chronic 
malarial  affections,  Osier  says  :  "  The  history  of  malarial  cachexia,  the 
absence  of  lymphatic  enlargement,  and  the  blood-condition  will  usu- 
ally be  sufficient  for  the  purpose  of  a  diagnosis.  Great  increase  in  the 
white  blood-corpuscles  is  not  often  seen  in  the  chronic  splenic  tumor 
of  malaria;  indeed,  they  may  be  much  diminished  in  number.  Toward 
the  end  in  very  chronic  cases  the  clinical  picture  may  be  very  similar; 
the  large  abdomen,  possibly  ascites,  dropsy  of  the  feet,  and  irregular 
fever  may  resemble  closely  splenic  leukaemia,  and  the  absence  of  an 
increase  in  the  colorless  corpuscles  may  be  the  only  marked  difference." 

Amyloid  spleen,  with  enlargement  of  the  organ,  occurs  in  conditions 
of  prolonged  suppuration,  especially  when  the  bones  are  involved,  and 
in  chronic  phthisis  and  syphilis.  The  spleen  is  enlarged,  hard,  and 
painless.  The  enlargement  is  rarely  great  enough  to  produce  distress 
on  that  account,  and  it  is  so  commonly  associated  with  a  similar  con- 
dition of  the  liver  and  kidneys,  if  not  of  other  organs,  that  any  con- 
stitutional symptoms  produced  by  the  spleen  are  apt  to  be  masked  by 
those  produced  by  other  organs. 

Hydatid  tumor  of  the  spleen  rarely  causes  any  symptoms  except 
when  it  becomes  very  large;  then  it  may  give  rise  to  discomfort  and 
a  dragging  pain  in  the  left  hypochondrium.  But  hydatid  tumors  of 
the  spleen  are  only  exceptionally  very  large;  when  large  enough  to 
admit  of  palpation,  and  when  the  tumor  is  situated  anteriorly  or  pro- 
jects from  the  lower  border  or  from  beneath  the  organ,  the  detection  of 
fluctuation,  the  withdrawal  of  the  characteristic  cystic  fluid  by  aspira- 
tion, and  possibly  the  hydatid  fremitus,  will  establish  the  diagnosis, 
when  taken  in  connection  with  the  gradual  development  of  the  tumor 
and  exposure  to  possible  infection.  In  the  absence  of  physical  signs 
of  a  cyst  the  nature  of  the  tumor  can  only  be  suspected  from  the 
habits  of  the  patient  or  his  place  of  residence.  Suppuration  of  the 
sac  may  be  brought  about  by  injury  or  rupture  into  the  adjacent  cavi- 
ties, with  grave  if  not  fatal  results. 

Inherited  syphilis  and  chronic  syphilis  are  accompanied  by  enlarge- 
ment of  the  spleen.  They  cause  a  chronic  interstitial  inflammation. 
The  enlargement  is  not  very  great,  and  does  not  present  characteristic 
features. 

Malignant  tumors  of  the  spleen  are  very  rarely  primary.  The  diag- 
nosis must  be  made  by  noting  malignant  disease  elsewhere,  the  very 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       661 

rapid  enlargement  of  the  spleen,  with  possibly  nodules  scattered  over 
its  surface,  and  the  presence  of  cachexia  and  the  usual  constitutional 
signs  of  a  malignant  disease. 

In  young  children  enlargement  of  the  spleen  is  not  uncommon.  It 
is  found  associated  most  frequently  with  rickets,  syphilis,  and  malarial 
poisoning,  and  has  been  attributed  to  each  of  these  diseases.  In  the 
London  Lancet,  April  30,  1892,  Dr.  J.  W.  Carr  analyzes  thirty  cases, 
and  comes  to  the  conclusion  that  the  enlargement  of  the  spleen  is  due 
to  splenic  anosmia,  the  esseutial  cause  being  unknown.  Rickets,  syph- 
ilis, and  ague  are  found  as  passing  causes  only,  since  the  disease  is 
found  in  some  cases  where  these  causes  can  be  excluded.  According 
to  this  author,  the  disease  is  extremely  rare  in  children  older  than  two 
and  one-half  years.  The  spleen  is  more  readily  palpated  in  children 
than  in  adults.  It  is  also  more  movable,  and  hence  by  bimanual  palpa- 
tion it  can  be  more  easily  brought  forward  to  the  median  line. 

Diseases  of  the  Pancreas. 

Just  as  the  functional  activity  of  the  pancreas  is  separated  with  diffi- 
culty from  that  of  other  functionally  related  organs,  so  the  aberration 
of  such  activity  is  discerned  with  the  greatest  difficulty.  As  the 
physiology  and  pathology  are  blended  so  the  symptoms  are  inter- 
mingled. 

The  pancreatic  secretion  aids  in  intestinal  digestion,  particularly  in 
emulsifying  fats,  hence  symptoms  due  to  disturbance  of  this  function 
are  looked  for,  and  it  is,  in  a  measure,  true  of  all  cases  of  pancreatic 
disease  that  there  is  some  intestinal  indigestion.  For  the  purpose  of 
determining  whether  the  function  of  digestion  of  fats  has  been  mod- 
ified the  patient  with  suspected  pancreatic  disease  is  given  fats  in  some 
form,  and  the  stools  are  watched.  If  fat  is  passed  in  the  stool  in  the 
amount  taken  by  the  mouth,  without  being  broken  up,  or  emulsified, 
it  is  held  as  proof  that  disease  of  the  pancreas  is  present.  While  fatty 
stools  may  be  indicative  of  pancreatic  disease,  the  absence  of  fat  in  the 
stools,  in  patients  who  are  fed  upon  it,  cannot  be  considered  to  exclude 
disease  of  this  orgau,  for,  notwithstanding  its  absence  in  a  large  num- 
ber of  instances  in  which  the  experiment  was  tried,  the  pancreas  was 
found  to  be  the  seat  of  grave  disease.  Sugar  has  been  observed  in  the 
urine  in  many  cases  in  which  the  pancreas  was  the  seat  of  the  disease. 
In  fact,  glycosuria  has  been  attributed  to  pancreatic  disease  in  cases  of 
grave  diabetes.  This  symptom,  however,  is  not  constant  in  pancreatic 
lesions.  Three  classes  of  symptoms — intestinal  indigestion,  fatty  stools, 
and  glycosuria — are,  therefore,  not  diagnostic  of  pancreatic  disease,  but 
only  afford  presumptive  evidence  of  its  presence. 

Tumor  of  the  'pancreas.  The  most  striking  symptoms  of  disease 
of  the  pancreas,  apart  from  those  due  to  the  morbid  process,  as 
suppuration  or  cancer,  are  those  due  to  a  tumor  pressing  upon  sur- 
rounding structures.  It  may  press  upon  the  gall-duct,  causing 
jaundice.  From  its  situation  in  the  epigastric  region  it  may  resemble 
an  aneurism,  or  a  tumor  of  the  pylorus  or  of  the  transverse  colon. 
Tumors  of  the  pancreas  are  usually  due  to  cancer.     This  is  usually  of 


662  SPECIAL  DIAGNOSIS. 

the  scirrhous  variety,  and  generally  primary.  The  enlargement  cannot 
be  distinctly  made  out  unless  the  patient  is  very  much  emaciated. 
"When  it  has  advanced  considerably  it  may  simulate  aneurism,  but  is 
distinguished  by  the  difference  in  the  character  of  the  pulsation.  In 
aneurism  the  pulsation  is  distensile,  in  disease  of  the  pancreas  it  is 
an  up-and-down  movement;  the  hand  is  lifted  with  each  pulsation 
of  the  aorta.  Tumor  of  the  pylorus  is  excluded  largely  because  of  the 
more  superficial  position  of  the  mass,  because  of  its  association  with 
pyloric  obstruction,  and  with  less  frequent  jaundice  than  in  disease  of 
the  pancreas.  A  pyloric  tumor  is  more  movable  and  may  change  posi- 
tion after  the  stomach  is  inflated  by  gas  or  distended  by  fluid.  Exam- 
ination with  the  patient  on  the  hands  and  kuees  may  aid  in  the  distinc- 
tion between  the  two.  In  a  tumor  of  the  transverse  colon  its  nearness 
to  the  surface  and  its  movability,  its  association  with  more  or  less 
constipation,  and  the  occurrence  of  intestinal  hemorrhage,  are  of  diag- 
nostic significance. 

The  general  symptoms  of  the  cancerous  cachexia;  the  occurrence  of 
intestinal  indigestion,  or  of  fatty  stools ;  the  gradual  onset  of  jaundice ; 
deep-seated  epigastric  pain  ;  an  immovable  tumor,  with  glycosuria, 
make  a  symptom-group  very  characteristic  of  cancer  of  the  pancreas. 

Hemorrhage.  We  owe  to  F.  W.  Draper  and  Prince  our  knowl- 
edge of  hemorrhage  into  the  pancreas.  Since  they  have  published  the 
result  of  their  labors  the  affection  has  been  frequently  recognized.  The 
attack  comes  on  suddenly  in  perfect  health,  and  usually  terminates  life 
in  a  short  period.  Nothing  in  the  occupation  or  conduct  of  the  patient 
at  the  time  is  known  to  favor  the  development  of  the  hemorrhage. 
He  is  seized  with  severe  pain,  which  is  localized  in  the  upper  part  of 
the  abdomen.  It  increases  in  severity,  and  may  intermit  like  colic. 
Nausea  and  vomiting  take  place  almost  at  the  same  time.  The  vomit- 
ing becomes  obstinate.  Extreme  depression  rapidly  sets  in  and  the 
patient  becomes  anxious  and  restless.  Collapse  ensues  in  a  short  time. 
The  extremities  become  cold  and  the  forehead  is  covered  with  sweat. 
The  pulse  increases  in  frequency,  and  rapidly  diminishes  in  strength. 
It  soon  becomes  imperceptible.  The  pain  and  vomiting  call  atten- 
tion to  the  upper  abdomen.  It  is  tender  on  pressure;  the  tenderness 
may  extend  throughout  the  entire  upper  half  of  the  abdomen.  Tym- 
panites may  develop.  There  is  constipation  in  many  cases.  The 
temperature  remains  normal,  or  becomes  subnormal.  The  pain,  the 
vomiting,  the  anxious  and  restless  state  continue  without  relief. 

From  the  above  group  of  symptoms  it  can  readily  be  seen  that  the 
diaguosis  is  obscure.  The  disease  can  be  taken  for  perforation  of  the 
stomach  by  ulcer,  although  the  vomiting  may  not  be  so  persistent  and 
frequent.  Intestinal  obstruction  in  the  upper  portion  of  the  tract  pre- 
sents allied  symptoms.  The  hemorrhagic  symptoms,  however,  are 
more  pronounced  in  pancreatic  hemorrhage.  Pallor  of  the  face  is 
sure  to  ensue.  The  vomiting  is  not  fsecal  in  character.  Constipation 
can  be  relieved.  It  is,  however,  difficult,  and  in  many  cases  impos- 
sible, to  establish  a  diagnosis.  The  rapidity  of  development  of  the 
symptoms  is  of  importance.  The  paiu  and  collapse  may  be  due  to 
rupture  of  an  aneurism  of  the  aorta. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.      663 

Acute  Hemorrhagic  Pancreatitis.  For  our  knowledge  of  this 
disease  we  are  indebted  to  Fitz.  He  collated  the  facts  from  the  liter- 
ature, and,  adding  the  results  of  his  own  valuable  observations,  has 
enabled  us  to  recognize  this  affection  during  life.  A  patient  with  hem- 
orrhagic pancreatitis  has  been  previously  subject  to  attacks  of  indiges- 
tion, attended  by  pain  and  vomiting;  many  use  alcohol  to  excess. 
The  attack  develops  suddenly,  resembling  somewhat  hemorrhage  of 
the  pancreas.  There  is  violent  pain  which  is  at  first  complained  of  in 
the  upper  abdomen,  although  it  is  sometimes  general.  Nausea  aud 
vomiting  are  present  in  all  the  cases,  constipation  in  most  of  them. 
The  abdomen  is  frequently  the  seat  of  tympanitic  distention.  In  many 
instances  an  obscure  tumor  cau  be  made  out  in  the  lower  epigastric 
region.  Collapse-symptoms  supervene,  although  fever  may  occur. 
The  cases  terminate  by  the  fourth  day,  even  earlier  in  some  cases.  The 
pain  and  collapse  are  probably  due  to  pressure  of  the  effused  blood 
upon  the  coeliac  plexus. 


Dulne 


Tumor  ol  the  pancreas. 

The  symptoms  resemble  acute  intestinal  obstruction,  an  irritant  poison, 

or  perforation  of  the  digestive  or  biliary  tract.  In  several  instances 
laparotomy  has  been  performed  for  the  relief  of  supposed  obstruction. 
The  intense  pain  in  the  epigastrium,  the  violent  vomiting  aud  disten- 
tion of  the  upper  abdomen,  without  a  possible  cause  for  obstruction, 
are  favorable  to  acute  pancreatitis.  The  difficulty  of  diagnosis,  how- 
ever, is  so  great  that  resort  to  laparotomy  is  justifiable  iu   order  to 


664  SPECIAL  DIAGNOSIS. 

determine  exactly  the  nature  of  the  condition.  In  a  most  interesting 
case  reported  by  W.  S.  Thayer,  the  diagnosis  of  acute  pancreatitis  (con- 
firmed by  laparotomy)  was  based  upon  the  history  of  previous  attacks 
of  pancreatic  pain,  with  fever,  vomiting,  and  collapse,  occurring  in 
an  adult,  who  was  over-fat  and  an  alcoholic;  the  exclusion  of  disease 
in  other  organs  and  the  absence  of  a  history  of  gallstones  or  gastric 
ulcer  or  abscess  from  other  causes;  the  occurrence  of  pain;  the  pres- 
ence of  a  deep-seated  tumor  which  gave  indistinct  signs  of  fluctuation, 
which  was  not  movable  with  respiration,  and  the  clulness  of  which  was 
not  continuous  with  or  of  the  same  character  as  that  of  adjacent  solid 
organs.  Epigastric  tympany  was  also  a  point  in  favor  of  pancreatic 
disease.  The  accompanying  figure  indicates  the  site  of  the  tumor  in 
Dr.  Thayer's  case. 

Suppurative  Pancreatitis.  Fitz  has  found  that  this  affection 
occurs  in  adults  under  forty  years,  more  f requently  in  males.  Symptoms 
continue  during  several  weeks  and  may  persist  for  a  year.  Pain  in  the 
epigastrium  is  complained  of,  associated  with  irregular  vomiting,  the 
latter  persisting  in  spite  of  care  as  to  feeding.  Fever  is  irregular  in 
type,  and  exhaustion  ensues.  In  a  case  under  my  observation  obstruc- 
tion of  the  portal  vein  took  place,  with  ascites.  The  latter  was  large, 
and  recurred  rapidly  after  tapping.  In  this  patient  pain  and  gastric 
disturbance  were  absent.  There  was  no  fever.  Emaciation,  constipa- 
tion, and  a  tumor  above  the  umbilicus  were  present;  the  emaciation 
was  extreme.  The  tumor  was  ill-defined,  painless,  apparently  super- 
ficial. Many  other  symptoms  of  pancreatic  disease  pointed  out  by 
Roberts  were  present.  Apathy  and  despondency  were  marked;  bronz- 
ing of  the  face  was  also  present.  The  patient  was  a  middle-aged  man, 
forty-two  years  old,  addicted  to  the  use  of  alcohol.  He  was  thought 
to  have  cirrhosis  of  the  liver.  As  happened  in  this  case,  the  pus  may 
accumulate  in  the  duodeno-jejunal  fossa  and  fill  up  the  cavity  of  the 
lesser  peritoneum,  with  more  pronounced  symptoms  of  tumor  than 
occur  in  similar  fluid  accumulations  in  the  above-mentioned  cavity. 

Gangrenous  Pancreatitis.  This  may  follow  later  upon  hemor- 
rhages into  the  pancreas.  The  symptoms  are  extremely  obscure. 
Symptoms  of  collapse  may  occur,  following  pain,  which  is  of  longer 
duration  than  in  the  acute  form,  or  vomiting,  which  is  not  so  persistent. 
A  patient  of  mine,  upward  of  sixty  years  old,  suffering  from  dyspep- 
sia, vomited  blood  in  the  course  of  an  illness  which  was  characterized 
by  loss  of  flesh  and  weakness.  The  anaemia  became  very  profound 
after  the  gastric  hemorrhage,  and  exhaustion  was  extreme.  There  was 
no  marked  tumor,  but  only  resistance  in  the  region  below  the  xiphoid. 
There  were  dulness  and  tubular  breathing  at  the  base  of  the  left  lung. 
Fever  was  absent.  Death  ensued  from  exhaustion.  A  small,  flat 
carcinoma  was  found  in  the  pyloric  end  of  the  stomach,  but  there  was 
no  perforation.  Gangrenous  pancreatitis,  with  signs  of  an  ante-mortem 
hemorrhage,  was  found.  The  accumulation  took  place  behind  the 
stomach  and  colon,  but  in  front  of  the  kidney;  its  outer  wall  was 
bounded  by  the  spleen.  It  was  circumscribed  above  by  the  diaphragm. 
Pleuritis  and  small  pulmonary  abscesses  at  the  base  of  the  left  lung 
were  found. 


DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PANCREAS.       665 

In  some  instances  the  pancreas  has  sloughed  into  the  bowel,  and  in 
two  such  cases  recovery  took  place  after  its  discharge  from  the  rectum. 

Chronic  pancreatitis  is  not  recognized  during  life,  although  its  pos- 
sible presence  must  be  considered  in  all  cases  of  diabetes. 

Cyst  of  the  Pancreas.  Cysts  of  the  pancreas  follow  impaction 
of  calculi  in  the  pancreatic  duct;  sometimes  the  biliary  calculi  obstruct 
the  orifice.  The  symptoms  are  those  of  tumor  in  the  upper  abdomen 
which  occupies  the  median  position,  or  is  chiefly  on  the  left  side  in  the 
upper  quadrant.  It  may  fill  the  abdominal  cavity  and  simulate  ovarian 
tumor.  It  usually  develops  slowly,  but  cases  of  rapid  onset  have  been 
described.  Fatty  diarrhoea  is  not  present.  There  is  a  sense  of  weight 
and  fulness  in  the  epigastrium.  The  cysts  are  not  really  true  cysts, 
but  accumulations  of  pancreatic  fluid  in  the  lesser  peritoneal  cavity. 
The  signs  are  those  of  tumor  to  the  left  of  the  median  line,  encroach- 
ing upon  the  left  lobe  of  the  liver  above,  and  extending  almost  to  the 
transverse  umbilical  line.  The  tumor  is  smooth,  and  may  fluctuate; 
it  is  not  hard  and  lobulated.  On  account  of  its  presence  the  dia- 
phragm may  be  arched  so  that  the  heart  is  dislocated  to  the  left  up- 
ward; the  apex  is  found  in  the  third  interspace.  It  also  causes  in- 
creased dulness  behind  on  the  left  side,  the  upper  border  approaching 
the  angle  of  the  scapula.  Exploratory  puncture  in  either  instance 
determines  the  nature  of  the  fluid,  and  may  determine  the  diagnosis. 
Boas  does  not  think  the  chemical  character  of  the  fluid  is  sufficient 
to  establish  a  diagnosis.  (See  Examination  of  Cystic  Fluid,  page 
175.1) 

Senn  has  pointed  out  that  in  cysts  of  the  pancreas  the  complexion  is 
peculiar;  it  is  described  as  an  unhealthy  yellow,  dirty,  or  earthy  hue. 
The  writer  also  considers  that,  in  the  diagnosis  of  pancreatic  cyst,  the 
history  of  the  case,  the  location  of  the  tumor,  and  its  relation  to  other 
organs  are  to  be  considered.  The  disease  occurs  in  adults,  and  usually 
follows  traumatism.  A  blow  in  the  epigastrium  is  a  prominent  excit- 
ing cause.  In  some  instances  it  occurs  after  an  attack  of  so-called 
biliary  colic  or  colicky  pains  in  the  upper  abdomen,  with  vomiting, 
but  without  jaundice,  characteristic  of  calculus  in  the  pancreatic  ducts. 
The  growth  of  the  tumor  is  unusually  rapid — a  point  in  favor  of  it& 
pancreatic  origin.  It  may  attain  an  enormous  size,  as  previously 
mentioned. 

In  contrast  to  cancer,  pain  is  absent.  Fatty  stools  are  absent.  Pre- 
vious gastro-intestinal  derangement  may  be  ascertained  upon  inquiry. 
Diabetes,  in  this  as  well  as  other  affections  of  the  pancreas,  may  be 
present.  The  cyst  is  always  found  at  first  in  the  region  occupied  by 
the  pancreas,  depending  somewhat  upon  the  portion  of  the  pancreas 

1  The  statement  as  to  the  character  of  the  fluid  of  pancreatic  cysts  described  on  page  175  must  be 
modified  as  follows:  It  is  not  necessary  that  albumin  or  fibrin  should  be  employed  in  performing 
this  test,  as  it  is  sufficient  to  add  milk  to  the  secretion  ;  when  in  such  cases  the  casein  ol  the  milk 
is  precipitated,  and  the  biuret  test  is  applied  to  the  resulting  filtrate,  and  the  test  compared 
with  a  control-milk  from  which  the  casein  has  been  removed  (this  can  be  done  by  adding  very 
dilute  acetic  acid  with  constant  stirring),  the  digestive  property  of  the  liquid  under  examination 
may  be  with  certainty  determined.  All  of  the  albumin  should  be  removed  from  the  filtrate  by  a 
saturated  solution  of  ammonium  sulphate.  Then  test  the  resulting  filtrate  with  the  biuret  test. 
The  peptone  would  not  be  precipitated  with  the  albumin,  and  as  all  albumins  give  the  same 
reaction  as  peptone  with  the  biuret  test,  the  albumin  should  be  removed  before  applying  the  test. 
Then  compare  with  the  control-test  as  above.  Erratum.  Third  line  of  footnote  p.  175,  read 
"  digest  albumin  appeared  to  be  great,  but  when  "  etc.,  instead  of  "  was  marked  "  etc. 


666  SPECIAL  DIAGNOSIS. 

from  which  it  originated.  It  may  be  below  the  right  lobe  of  the  liver, 
below  the  xiphoid,  or  in  the  left  upper  quadrant.  In  the  great  major- 
ity of  cases  it  occupies  the  last  situation.  It  displaces  the  stomach 
forward  and  to  the  right,  the  transverse  colon  downward,  the  diaphragm 
and  the  contents  of  the  chest  upward.  The  cyst  may  be  movable  in 
respiration. 

Diagnosis.  It  must  be  distinguished  from  cancer  of  the  pancreas  or 
adjacent  organs,  aneurism,  hydatid  cyst  of  the  liver,  the  spleen,  or  the 
peritoneum,  affections  of  the  retro-peritoneal  glands,  hydronephrosis, 
cystic  disease  of  the  suprarenal  capsule,  circumscribed  peritonitis  with 
exudation,  ascites,  cystic  disease  of  the  ovary.  Pain  is  an  important 
symptom  of  disease  of  the  pancreas  in  its  more  acute  manifestations; 
it  must  be  distinguished  from  the  pain  of  intestinal  obstruction  and 
the  pain  of  perforative  peritonitis.  The  pain  is  always  localized  in 
the  region  below  the  xiphoid,  or,  if  general,  is  confined  to  the  upper 
half  of  the  abdomen.  It  exactly  simulates  the  pain  of  the  affections 
just  described.  This  resemblance  is  more  pronounced  because  of  the 
association  of  vomiting  and  collapse  in  obstruction  and  perforative 
peritonitis.  Pain,  although  not  so  intense,  but  of  a  colicky  nature, 
attended  by  diarrhoea  or  constipation,  in  some  instances  with  intestinal 
hemorrhage,  may  be  due  to  calculous  disease  of  the  pancreas.  Fre- 
quently this  form  of  pain  can  be  recognized  if  other  symptoms  of 
pancreatic  disease,  such  as  glycosuria,  steatorrhcea,  and  intestinal 
indigestion,  are  present. 


CHAPTER   VII. 

DISEASES  OF  THE  KIDNEYS. 

The  kidneys  are  affected  by  disease  from  several  sources.  First, 
the  great  vascular  supply  is  subject  to  the  alteration  which  takes  place 
in  any  large  arterial  area  either  from  direct  hypersemia,  through  the 
influence  of  the  vasomotor  nerves  (see  Hyperemia),  or  from  passive 
hypersemia  or  congestion  through  the  central  organ  of  the  circulation. 
Second,  the  bloodvessels  are  the  seat  of  thrombosis  and  embolism,  par- 
ticularly the  latter,  causing  renal  infarction.  Third,  infectious  mate- 
rial is  carried  to  the  kidney,  and,  in  passing  through  the  structure, 
gives  rise  to  the  inflammations  we  see  in  infectious  disease,  either  of 
an  infective  or  simply  of  an  irritative  character.  Fourth,  through 
the  means  of  the  bloodvessels  also  the  renal  structure,  by  virtue 
of  its  function,  is  particularly  liable  to  irritant  inflammation,  for 
through  it  pass  poisons  that  are  ingested,  and  the  products  of  meta- 
morphosis which,  if  modified  in  character  or  increased  in  amount, 
excite  irritation  and  lead  to  inflammatory  changes. 

But  the  kidney  is  open  to  attack  from  sources  lower  down  in  the 
urinary  tract.  Through  the  bladder  and  ureter  infection  may  extend 
upward,  causing  the  consecutive  inflammatory  processes  which  are 
often  seen  after  disease  of  the  urethra,  bladder,  or  ureter.  It  is  obvi- 
ous that,  if  changes  in  the  urine  are  found,  one  of  these  three  causal 
conditions  may  be  present.  The  kidney  is  at  the  apex  of  a  system  of 
tubes  or  channels.  Any  alteration  of  them,  whether  mechanical  or 
functional,  has  a  secondary  effect  upon  the  kidney.  Obstruction  of  the 
ureter, or  obstruction  in  the  conduits  beyond, leads  to  consecutive  hyper- 
trophy, inflammation,  and  atrophy.     (See  Morbid  Processes.) 

The  morbid  processes  which  may  take  place  in  the  kidney  are  such 
as  are  common  to  all  organs — congestion,  degeneration,  inflammation, 
and  morbid  growth.  The  symptoms  that  attend  the  morbid  processes 
are  such  as  accompany  similar  processes  elsewhere.  The  general  symp- 
toms of  the  morbid  processes  are  not  pronounced  except  in  the  case  of 
intense  inflammation  with  suppuration,  or  of  morbid  growths,  as  car- 
cinoma, because  of  the  small  size  of  the  kidney.  Otherwise,  general 
symptoms  in  renal  disease  are  of  small  moment,  except,  as  is  usually 
the  case,  when  there  is  interference  with  the  function.  Pain  is  the 
only  local  symptom  due  to  the  morbid  process. 

The  symptoms  of  renal  disease  are  due  to  the  morbid  process,  or  to 
its  functional  or  anatomical  alteration  of  the  kidney.  But  the  structure 
is  so  closely  interwoven  with  the  function  that  morbid  changes  in  one 
imply  morbid  changes  in  the  other.  As  the  anatomical  alterations  are 
usually  beyond  the  pale  of  investigation,  we  find  that  functional  symp- 
toms alone  are  apparent.      Hence,   in  each  morbid  process  we  look 


668  SPECIAL  DIAGNOSIS. 

for  changes  in  the  urine,  which  is  the  product  of  renal  function,  and  for 
symptoms  resulting  from  abeyance  or  cessation  of  the  function.  Rarely 
we  have  enlargements  due  to  tumor,  as  cancer  or  abscess,  or  to  obstruc- 
tion of  the  channels,  causing  hydronephrosis,  or  to  parasitic  disease. 

The  urine  is  not  simply  an  index  of  the  condition  of  the  kidneys.  It 
varies,  within  the  bounds  of  health,  in  color,  quantity,  and  quality. 
Food,  exercise,  and  other  conditions  modify  the  secretion.  It  can 
readily  be  seen,  therefore,  that  any  general  disease  and  many  local  dis- 
eases cause  alterations  in  the  character  of  the  urine.  Any  abnormal 
urine,  therefore,  is  symptomatic  of  renal  disease  or  of  disease  beyond 
the  point  at  which  the  urine  passes  out  of  the  body.  Usually  abnor- 
mal changes  in  the  urine,  due  to  the  general  condition,  do  not  give  rise 
to  local  renal  symptoms  or  to  abnormal  renal  function.  The  exception 
is  seen  when  an  excess  of  uric  acid,  or  of  urates,  or  of  oxalates  is 
passed.  They  may  give  rise  to  local  pain  and. may  set  up  sufficient 
irritation  to  cause  albuminuria. 

A.  The  general  phenomena  of  the  morbid  processes  are  fever  and 
emaciation.  Fever  occurs  in  acute  nephritis,  perinephritic  abscess,  sup- 
purative and  tuberculous  nephritis,  pyelitis,  and,  with  twists  of  the 
ureter,  in  floating  kidney.  Emaciation  occurs  in  chronic,  suppurative, 
and  tuberculous  nephritis  and  carcinoma.  The  local  phenomena  of 
morbid  processes  are  pain  and  tumor. 

B.  The  symptoms  due  to  the  alteration  of  function  are  :  1 .  Urcemia. 
2.  Car dio- vascular  symptoms.  3.  Ancemia.  4.  Dropsy.  5.  Changes 
in  the  character  of  the  urine.  6.  Changes  in  the  frequency  and  char- 
acter of  the  micturition.  The  symptoms  of  renal  disease  are,  there- 
fore, both  subjective  and  objective. 

Classification.  The  best  classification  of  diseases  of  the  kidneys 
is  that  based  upon  the  propositions  of  Delafield,  who,  in  a  paper 
entitled  "  On  the  Diseases  of  the  Kidneys  Popularly  Called  '  Bright7  s 
Disease,'  m  submitted  a  classification  dependent  upon  the  nature  of 
the  morbid  process.  The  morbid  processes  included  congestions,  degen- 
erations, and  inflammations  of  the  renal  structure.  In  addition  to 
these  affections  we  must  also  include  in  the  nosology  of  renal  disease 
tumors  (cancer,  abscess,  and  hydronephrosis),  and  anomalies  of  growth 
or  position  (floating  kidney,  horseshoe  kidney),  affections  due  to  inva- 
sion of  the  kidney  by  parasites,  and  affections  due  to  obstruction  of 
the  tubes  through  which  the  offices  of  the  kidney  are  carried  on  (renal 
calculus,  hydro-  and  pyonephrosis). 

The  Data  Obtained  by  Inquiry.     The  Subjective  Symptoms. 

The  subjective  symptoms  are  due  to  morbid  processes  within  the 
kidney  or  to  alterations  of  its  function.  The  class  of  nervous  symp- 
toms which  belong  to  uraemia  are  subjective  in  character,  as  are  also 
the  symptoms  of  movable  kidney. 

Pain.  Pain  in  the  kidneys  is  referred  to  the  loins.  It  is  complained 
of  as  a  dull  aching,  sometimes  increased  by  movement,  often  attended 

1  Trans.  Amer.  Physicians,  vol.  vi.,  1S91,  p.  124. 


DISEASES  OF  THE  KIDNEYS.  669 

by  a  sense  of  weight  or  pressure.  This  form  or  kind  of  pain  extends 
over  the  entire  lumbar  region  and  is  due  to  disease  of  both  kidneys, 
as  in  acute  nephritis.  We  have,  further,  pain  referred  to  oue  kid- 
nev.  The  pain  may  be  seated  in  the  region  of  the  kidney  behiud, 
opposite  the  two  lower  dorsal  and  two  upper  lumbar  vertebral  spines, 
or  deep-seated  in  the  abdomen,  to  the  right  or  left  of  the  spinal  column 
below  the  level  of  the  umbilicus.  It  is  not  generally  mistaken  for 
pain  due  to  other  •  causes,  as  myalgia,  or  disease  of  the  vertebrae.  If 
mvalgic,  it  may  follow  exposure  to  cold  and  be  associated  with  pain  in 
other  muscles.  Neuralgia  of  the  kidneys  no  doubt  occurs.  It  may 
be  due  to  malaria,  lead-poisoning,  gout,  or  anaemia.  It  partakes  of 
the  characters  of  neuralgia  elsewhere. 

The  unilateral  pain  above  mentioned  may  be  constant  or  paroxys- 
mal. Constant  pain  is  usually  due  to  organic  disease  of  the  kidney, 
as  carcinoma  or  tuberculosis.  It  may,  however,  be  due  to  the  impac- 
tion of  a  calculus  in  the  pelvis  of  the  kidney.  Paroxysmal  and  lanci- 
nating pain,  the  paroxysms  recurring  at  long  intervals,  is  usually 
due  to  renal  calculus,  or  to  the  presence  of  a  foreign  substance,  as 
blood,  in  the  pelvis  of  the  kidney.  The  pain  is  seated  not  only  in 
the  regions  just  indicated,  but  extends  along  the  ureter,  from  the  loin 
to  the  front  of  the  abdomen.  It  may  persist  for  some  time,  at  a  point 
on  either  side  of  the  umbilicus  above  or  below  it,  or  at  a  point  on  the 
surface  of  the  abdomen  opposite  the  brim  of  the  pelvis.  Thence  the 
pain  extends  into  the  bladder  either  above  the  pubis  (the  hypogas- 
tric region),  or  into  the  testicle,  or  down  the  inside  of  the  thigh.  It 
may  be  in  the  loin  and  at  the  end  of  the  penis  at  the  same  time,  or 
lancinate  along  the  whole  urinary  tract.  In  rare  cases  the  pain  is  in 
the  kidney  of  the  healthy  side.  The  pain  of  renal  colic  is  always  asso- 
ciated with  frequency  of  micturition,  with  or  without  pain  during  the 
passage  of  the  urine.  The  character  of  the  urine  often  points  to  the 
cause  of  the  pain.  The  urine  is" usually  bloody,  and  at  first  scanty; 
when  the  obstruction  is  removed,  it  becomes  copious.  Renal  pain  or 
colic  located  in  front  of  the  abdomen  must  not  be  confounded  with  the 
pain  of  hepatic  or  intestinal  colic.  The  pain  is  usually  lower  than  in 
hepatic  colic,  extends  along  the  course  of  the  ureter,  and  is  attended 
by  symptoms  referable  to  the  urinary  and  not  to  the  hepatic  system. 
Paroxysmal  pains  of  great  severity  may  attend  movable  kidney  (q.  v.), 
and  are  known  as  Dietl's  crises. 

In  tumors  the  pain  may  follow  the  course  of  the  sciatic  nerve,  sim- 
ulating sciatica.  In  pyelitis  and  hydronephrosis  the  pain  is  of  a  teariug 
character,  whereas  in  movable  kidney  it  is  variable. 

Neuralgia.  Neuralgia  is  a  symptom  of  common  occurrence  in  the 
course  of  Bright' s  disease.  It  may  be  due  to  anaemia,  or  be  of  uraemic 
origin.  The  occipital,  supra-orbital,  or  trifacial  nerve,  or  other  nerves, 
may  be  affected.  Anginoid  seizures,  attended  by  pain,  are  of  frequent 
occurrence. 

Frequency  of  Micturition.  There  are  four  causes  of  frequent  mic- 
turition :  (1)  disease  of  the  kidneys,  the  ureters,  or  the  bladder,  on 
account  of  irritability  of  the  genito-urinary  tract;  (2)  diseases  in  which 


670  SPECIAL  DIAGNOSIS. 

the  amount  of  urine  is  increased,  demanding  very  frequent  efforts  to 
relieve  the  distention,  as  in  diabetes;  (3)  diseases  in  which  the  urine 
is  more  concentrated,  and  hence  causes  more  pronounced  irritation,  as 
in  fevers,  gout,  or  acute  nephritis;  (4)  a  reflex  or  pure  neurosis. 

Increased  frequency  of  micturition  occurs  in  almost  all  organic  affec- 
tions of  the  genito-urinary  system.  It  is  seen  in  all  forms  of  conges- 
tion and  inflammation  of  the  kidneys.  In  chronic  nephritis  it  may 
not  be  noticed  save  that  the  patient  is  called  upon  to  pass  urine  at 
night,  arousing  him  from  sleep  for  this  purpose.  In  some  forms  of 
nephritis  the  increased  frequency  may  be  due  to  increase  in  the  amount 
of  urine  as  well  as  to  increased  sensitiveness  of  the  organs.  In  the 
organic  diseases  it  always  occurs.  The  disease  is  not  limited,  how- 
ever, to  the  kidneys.  Disease  of  the  ureter  and  disease  of  the  bladder 
are  also  associated  with  this  troublesome  symptom.  It  occurs  in  its 
most  aggravated  and  characteristic  form  in  renal  calculus,  or  when 
any  foreign  substance  is  located  in  the  ureter  or  bladder.  The  fre- 
quency amounts  to  six,  eight,  or  even  a  dozen  times  in  an  hour.  It 
is  often  associated  with  tenesmus,  the  patient  having  a  constant  desire 
to  urinate,  at  the  same  time  passing  but  small  amounts.  This  form 
of  tenesmus  is  more  frequent  when  the  bladder  or  urethra  is  the  seat 
of  disease,  and  in  renal  calculus. 

The  Data  Obtained  by  Observation.     The  Objective  Symptoms. 

The  objective  symptoms  of  diseases  of  the  kidney  are:  (1)  phys- 
ical changes  of  the  organ;  (2)  physical  and  chemical  changes  in  the 
urine  ;  (3)  impairment  of  the  function.  Symptoms  due  to  impairment 
of  the  function  are  both  objective  and  subjective. 

Physical  Examination.  Palpation  and  Percussion.  The 
kidneys  are  situated  in  the  right  and  left  lumbar  regions  respectively, 
the  left  being  a  little  higher  than  the  right.  They  extend  from  the 
eleventh  rib,  or  twelfth  dorsal  vertebra,  to  the  third  dorsal  vertebra. 
The  left  kidney  is  in  contact  above  with  the  spleen,  and  the  right  with 
the  liver.  The  kidneys  are  enveloped  in  more  or  less  abundant  fat; 
their  distance  from  the  anterior  surface  of  the  abdomen  renders  them 
inaccessible  to  percussion  from  that  direction,  and  the  thick  dorsal 
and  lumbar  tissues,  coupled  with  the  relation  of  the  kidneys  with  the 
organs,  spleen  and  liver,  which  give  a  dull  note  on  percussion,  make 
it  difficult  to  outline  the  kidneys  from  behind. 

Palpation  of  the  normal  kidney  is  difficult.  It  can  only  be  bimanual. 
Place  the  fingers  of  one  hand  below  the  last  rib  outside  of  the  lumbar 
muscles — erector  spinse — and  apply  the  other  below  the  ribs  in  front. 
Firm,  persistent  pressure  with  the  abdominal  muscles  relaxed  will 
often  enable  the  normal  kidney  to  be  felt. 

Palpation  of  the  kidney  becomes  easy  when  it  is  either  enlarged 
or  displaced.  In  the  case  of  an  enlarged  kidney  the  patient  should 
lie  upon  his  back  or  be  slightly  turned  to  the  opposite  side;  one  hand 
is  placed  beneath  the  kidney  and  pressed  upward,  while  the  other  is 
pressed  firmly  and  steadily  from  above,  or  laterally  toward  the  kidney. 


DISEASES  OF  THE  KIDNEYS.  671 

Iii  this  manner  the  kidney  can  be  grasped  between  the  two  hands,  its 
size  estimated,  and  its  physical  characteristics  as  regards  hardness, 
softness,  fluctuation,  and  mobility  determined.  Enlargements  are  also 
detected  by  palpation  of  the  abdomen.  (See  Palpation  of  the  Abdo- 
men.) In  thin  subjects  the  kidney  can  be  felt  by  abdominal  palpation, 
if  the  muscles  are  relaxed.  The  fact  that  it  moves  a  little  with  res- 
piration aids  in  its  detection;  and  if  it  is  unusually  movable  the  edge 
of  the  hand  can  be  slipped  above  its  upper  end,  by  turning  edgewise 
that  border  of  the  hand  which  is  adjacent  to  the  ribs.  A  renal  tumor 
is  usually  two  to  three  inches  to  either  side  of  the  median  line,  a  little 
above  the  transverse  umbilical  line. 

A  very  favorable  position  for  palpating  movable  kidneys  is  that 
assumed  by  standing  and  leaning  forward  over  a  chair,  with  the  trunk 
supported  by  the  hands  resting  on  the  seat  of  the  chair.  In  this  posi- 
tion the  abdominal  muscles  are  relaxed  and  the  kidneys  fall  forward. 

Percussion.  The  best  results  are  obtained  by  having  the  patient  lie 
face  downward,  and  placing  a  cushion  under  the  belly  so  as  to  make 
the  lumbar  regions  a  little  more  prominent.  Strong  percussion  is 
required,  and  an  artificial  plessor  and  pleximeter  are  to  be  preferred. 
Percussion  should  be  conducted  with  a  view  to  marking  the  angle 
which  the  liver-dulness  and  splenic  dulness  make  with  that  of  the  kid- 
ney on  the  right  and  left  sides,  respectively.  The  kidneys  extend 
below  the  lower  lines  of  liver  and  splenic  dulness,  and  laterally  for  a 
width  not  greater  than  four  inches.  The  difficulties  in  the  way  of 
outlining  the  kidneys  by  percussion  are  greatly  increased  in  persons 
with  much  flesh,  or  when  the  abdominal  walls  are  waterlogged,  as 
they  become  in  ascites,  and  it  is  practically  impossible,  under  such 
circumstances,  to  be  sure  of  the  boundaries  of  the  kidneys.  The 
colon  must  be  empty  to  yield  trustworthy  results.  Enlargements  of 
the  kidney  may  be  detected  by  percussion;  the  width  of  the  kidney 
is  increased,  and  the  percussion-dulness  therefore  extends  further  to 
the  right  or  left,  according  as  the  right  or  left  kidney  is  affected. 
As  the  causes  which  produce  enlargements  of  the  kidney  sufficiently 
great  to  be  detected  by  percussion  do  not,  with  rare  exceptions, 
involve  both  kidneys  at  the  same  time,  comparison  of  the  two  sides 
is  of  great  value  in  the  diagnosis. 

The  diseases  of  the  kidney  attended  by  enlargement  are:  malignant 
tumors,  tuberculosis,  cysts,  abscess,  hydro-  and  pyonephrosis,  and  peri- 
nephritic  abscess. 

In  abscess  of  the  kidney  there  is  some  fulness  in  the  loin  of  the 
affected  side.  The  kidney  is  felt  to  be  enlarged,  and  is  tender  and 
painful.  A  tumor  may  be  detected  anteriorly.  The  diagnosis  is  based 
on  a  study  of  the  cause  (acute  nephritis,  pyaemia,  impacted  calculus  in 
the  ureter,  erysipelas),  or  the  detection  of  blood  and  pus  in  the  urine, 
which  is  scanty,  and  on  the  constitutional  symptoms.  The  progress 
of  the  case  is  usually  acute.  If  the  abscess  is  tubercular,  tubercle- 
bacilli  can  be  detected  in  the  purulent  sediment  of  the  urine,  and  there 
will  be  other  foci  of  tuberculosis  with  a  corresponding  clinical  history. 

In  malignant  tumors  of  the  kidney  the  surface  is  no  longer  smooth, 
and  nodules  may  be  felt." 


672  SPECIAL  DIAGNOSIS. 

In  pyonephrosis  the  tumor  is  tense,  smooth,  and  globular.  Fluctu- 
ation may  be  detected.  Tenderness  is  usually  absent;  the  course  is 
slow  and  does  not  affect  the  general  health  so  much  as  abscess. 
The  pus  may  be  discharged  copiously  from  time  to  time,  and  the 
tumor  be  therefore  diminished  in  size.  The  urine  may  be  occasion- 
ally almost  clear.  Pyonephrosis  arises  secondarily  to  pyelitis,  and 
often  after  the  latter  has  lasted  some  time. 

Hydronephrosis  consists  in  a  dilatation  of  the  kidney  pelvis  with 
urine,  which  is  prevented  from  escaping  by  obstruction  of  the  ureter, 
either  by  the  pressure  of  a  tumor,  or  by  disease  of  the  bladder  or 
ureter  itself.  In  time  the  kidney  atrophies  from  the  pressure  and  a 
large  cyst  forms.  The  tumor  has  the  physical  characteristics  of  pyo- 
nephrosis, but  the  history  is  different,  and  if  there  is  any  discharge, 
it  is  free  from  pus.  As  in  pyonephrosis,  the  tumor  may  become  small, 
following  a  copious  discharge — in  this  case  of  urine — or  may  even  wholly 
disappear,  if  the  obstruction  is  removed.     This  sign  is  pathognomonic. 

If  obstruction  continue  to  be  absolute,  the  diagnosis  must  be  made 
by  the  detection  of  a  fluctuating  renal  tumor,  the  absence  of  fever  and 
signs  of  suppuration,  and  by  the  result  of  exploratory  puncture.  The 
urine  is  usually  free  from  pathological  changes. 

It  may  be  confounded  with  ascites,  if  very  large,  but  hydronephrosis 
is  rarely  bilateral,  and  the  fluid  in  it  does  not  change  its  level  upon 
change  of  position  of  the  patient,  as  is  the  case  with  ascites.  The 
history  of  the  two  conditions  will  be  different. 

An  ovarian  cyst  can  usually  be  traced  into  the  pelvis;  it  does  not 
carry  the  colon  in  front  of  it,  and  hence  is  dull,  even  on  superficial 
percussion,  and  it  leaves  the  loins  resonant. 

A  hydatid  cyst  of  the  kidney  presents  the  usual  physical  signs  of 
such  cysts.  A  fremitus  may  be  detected,  or  small  cysts  may  be  found 
in  the  urine. 

In  the  diagnosis  of  renal  tumors,  in  general,  it  should  be  borne  in 
mind  that  they  are  very  rarely,  almost  never,  movable  with  respiration. 
Unless  too  large  they  preserve  their  reniform  shape,  and  press  in  front 
of  them  the  ascending  or  descending  colon,  whereas  ovarian  tumors  lie 
behind  it.  The  position  of  the  colon  should,  therefore,  always  be 
ascertained,  and  to  this  end  it  may  be  necessary  to  inflate  it. 

Perinephritis  arises  usually  from  extension  of  inflammation  and  sup- 
puration from  the  kidney,  but  may  be  the  result  of  strain,  exposure 
to  cold,  or  injury.  Perinephritis  may  also  be  pysemic,  and  occur  after 
infectious  fevers. 

The  swelling  of  a  perinephritic  abscess  appears  in  the  lumbar  region 
of  the  side  affected.  It  is  rounded  in  form  and  doughy  (Da  Costa). 
Like  other  kidney  tumors  it  is  not  affected  by  respiration.  The  usual 
signs  of  confined  suppuration  exist,  and  pulmonary  or  pleural  compli- 
cations may  occur.  As  the  abscess  progresses,  the  local  signs  of  sup- 
puration become  more  marked,  the  skin  reddens,  and  pus  may  be 
discharged  externally. 

The  most  marked  subjective  symptom  is  pain,  which  may  amount 
to  agony,  and  is  paroxysmal;  soreness  from  restricted  motion  of  the 
psoas  muscle  is  apt  to  be  complained  of. 


DISEASES  OF- THE  KIDNEYS.  673 

.V  tumor  was  present  in  the  loins  in  sixty-five  out  of  seventy-one 
cases  analyzed  by  Fenwick,  but  did  not  generally  manifest  itself  until 
the  inflammation  had  made  considerable  progress.  There  is  dulness 
on  percussion  even  in  the  early  stage,  and,  later,  fluctuation.  The  gen- 
eral .symptoms  are  vomiting,  constipation,  fever,  and  sometimes  rigors. 
It  is  more  common  in  males  than  in  females  (sixty-one  males  to  thirty- 
nine  females  in  Fenwick' s  cases),  and  is  most  apt  to  occur  in  persons 
who  have  suffered  from  renal  calculi,  pyelitis,  or  scrofulous  kidney, 
and  after  operations  in  the  bladder  and  urethra,  or  when  the  patient 
has  been  subjected  to  injuries  or  strains  of  the  loins,  or  to  exposure  to 
cold  or  wet  when  in  a  heated  condition  (Fenwick). 

Movable  kidney  is  best  detected  by  palpation.  It  is  recognized  by 
its  rounded  borders,  its  bean  shape,  its  movability,  the  detection  of  the 
hilus  and  perhaps  of  the  pulsation  of  vessels  in  it,  and  by  the  fact  that 
it  can  be  replaced.  Palpation  causes  a  sickening  feeling,  analogous 
to  that  experienced  when  a  testicle  is  compressed,  but  less  in  degree. 
A  knee-chest  position  facilitates  palpation;  it  should  always,  however, 
be  conducted  with  patient  in  the  upright  position.  The  value  of  rela- 
tive percussion  over  the  two  kidney  regions  as  a  means  of  showing  the 
absence  of  the  kidney  is  much  overrated.  Percussion  will,  however, 
demonstrate  that  a  body,  supposed  from  palpation  to  be  the  kidney,  is 
a  solid  organ.  The  patient  with  movable  kidney  suffers  from  a  feel- 
ing of  lack  of  support  in  that  region,  which  induces  inaptitude  and 
perhaps  inability  to  work.  The  urine  itself  does  not  usually  present 
any  abnormalities. 

Malignant  tumors  of  the  kidney,  when  primary,  occur  in  a  large 
number  of  cases  in  children.  Twenty -five  out  of  sixty-seven  cases 
collected  by  Dr.  William  Roberts  occurred  in  children  under  ten  years 
of  age.  The  most  important  symptoms  are  pain,  hsematuria,  and 
tumor.  The  latter  may  grow  with  great  rapidity  and  attain  enormous 
size,  filling  the  abdominal  cavity  and  giving  rise  to  pressure-symptoms 
in  surrounding  organs.  The  growth  occurs  more  often  anteriorly  and 
downward  toward  the  pubis,  because  there  is  less  resistance  in  these 
directions.  On  palpation  of  the  abdomen  the  tumor  may  appear 
smooth,  or  irregular  and  undulated.  As  rapidly  growing  cancers  are 
soft,  the  tumor  frequently  exhibits  a  certain  degree  of  elasticity,  which 
may  be  mistaken  for  fluctuation.  It  is  immovable  either  by  the  hands 
or  with  respiration. 

On  percussion  the  resistance  is  increased  and  the  note  is  dull,  except 
in  front,  where  the  colon,  which  has  been  pushed  forward,  gives,  a 
tympanitic  note.  If  the  colon  should  be  flattened  out  between  the 
tumor  and  the  abdominal  wall,  it  may  be  felt  as  a  band  stretching 
across  the  tumor,  with  dulness  on  percussion.  In  such  a  case  inflation 
of  the  colon  will  be  of  great  assistance  in  the  diagnosis.  Rare  phys- 
ical signs  are  pulsation  and  a  blowing  murmur. 

Examination  by  Special  Instruments.  Examination  of  the  bladder, 
the  ureters,  and  the  pelvis  of  the  kidney  has  been  wonderfully  ad- 
vanced by  the  genius  of  Howard  Kelly.  The  following  instruments 
are  required  for  the  examination  of  the  bladder  :  Female  catheter  ; 
urethral  calibrator  ;  a  series  of  urethral  dilators  ;  a  series  of  specula  with 

43 


674  SPECIAL  DIAGNOSIS. 

obturators  ;  common  head-mirror  and  a  lamp,  Argand  burner,  or  elec- 
tric light ;  long,  delicate  mouse-toothed  forceps  ;  suction-apparatus  for 
completely  emptying  the  bladder  ;  ureteral  searcher  ;  ureteral  catheter 
with  a  handle  ;  small  bran-bags  for  elevating  the  pelvis. 

The  procedure  is  as  follows  :  Empty  the  bladder;  measure  the  mea- 
tus urinarius  externus;  dilate  the  urethra  to  twelve  or  fifteen  milli- 
metres; insert  speculum  of  diameter  of  last  dilator,  aud  remove  obtu- 
rator; elevate  the  hips  of  the  patient  about  a  foot  above  the  level  of  the 
table  ;  inspect  with  light ;  remove  residual  urine  by  suction  or  with 
cotton  and  mouse-toothed  forceps. 

For  anaesthesia  a  pledget  of  cotton  saturated  with  a  5  per  cent,  solu- 
tion of  cocaine  may  be  introduced  seven  minutes  before  dilatation.  On 
removal  of  the  obturator  the  bladder  becomes  distended  with  air.  The 
bladder  is  viewed  by  turning  the  speculum,  and  each  ureteral  orifice  is 
brought  into  view  by  turning  the  speculum  thirty  degrees  to  one  side 
or  the  other.  Kelly  says  :  "  The  orifice  appears  as  a  dimple  or  a  little 
pit,  or,  iu  inflammatory  cases,  as  a  round  hole  in  a  cushioned  eminence; 
at  other  times  as  a  ^  with  the  point  directed  outward;  again,  it  may  be 
scarcely  visible  even  to  a  trained  eye,  appearing  as  a  fine  crack  in  the 
mucosa,  and  occasionally  is  so  obscure  as  to  be  recognized  only  by  the  jet 
of  urine  as  it  escapes,  or  by  a  slight  difference  in  the  color  -of  the 
mucous  membrane  at  that  point.  In  rare  cases  it  has  the  form  of  a 
truncated  cone  with  gently  sloping  sides  ;  this  appearance  is  most  apt 
to  be  developed  in  the  knee-breast  position.  The  bladder  mucosa  is 
usually  of  a  slightly  deeper  rose  color  around  the  ureter,  and  in  the 
presence  of  an  inflammatory  process  it  even  appears  deeply  injected." 

Catheterization  of  the  ureters.  The  catheters  are  sterilized;  they  are 
stiffened  with  a  wire  stylet.  The  orifice  is  exposed  and  then  the  outer 
end  of  the  catheter  being  held  over  the  shoulder  by  an  assistant,  the 
conical  end  is  introduced  and  pushed  up  the  ureter,  while  at  the  same 
time  the  stylet  is  being  removed.  The  speculum  is  removed  and  again 
introduced  along  the  first  catheter.  The  remaining  ureter  is  then  cath- 
eterized ;  both  are  properly  designated  and  allowed  to  drain  into  test- 
tubes  plugged  with  sterilized  cotton  and  fixed  in  a  block  of  wood.  By 
catheterization,  aspiration,  and  exploration  of  the  ureters  with  a  bougie, 
the  source  of  pyaemia  anywhere  from  the  urethral  orifice  to  the  renal 
pelvis,  can  be  found ;  renal  calculi  diagnosticated ;  strictures  of  the 
ureter  located ;  hydronephrosis  distinguished  from  soft  malignant 
growths ;  and  the  functional  value  of  each  kidney  determined. 

Kelly  suggests  the  following  guide  to  the  ureteral  orifice  :  "A  point 
is  marked  on  the  cystoscope  5  J  cm.  from  the  vesical  end,  and  from  this 
point  two  diverging  lines  are  drawn  toward  the  handle  with  an  angle  of 
sixty  degrees  between  them.  The  speculum  is  introduced  up  to  the 
point  of  the  V,  and  turned  to  the  right  or  left  until  one  side  of  the  V 
is  in  line  with  the  axis  of  the  body ;  then  by  elevating  the  endoscope 
until  it  touches  the  floor  of  the  bladder  the  ureteral  orifice  will  usually 
be  found  within  the  area  covered  by  the  orifice  of  the  speculum." 

By  means  of  a  searcher,  or  sound,  the  suspected  orifice  is  further 
examined. 


DISEASES  OF  THE  KIDNEYS.  675 


Examination  of  the  Urine. 


1.  Inspection.  The  urine  in  health  is  a  clear  yellow  or  amber- 
colored  fluid,  having  a  specific  gravity  of  about  1020,  and  generally 
acid  in  reaction.  It  contains  normally  about  forty-five  parts  in  the 
thousand  of  solid  matter,  the  principal  part  of  which  is  urea — twenty- 
one  and  a  half  parts.  The  other  solids  are  uric  acid  and  its  salts  ; 
certain  extractives — creatin,  creatinin,  ammonia,  hippuric  acid,  xan- 
thin,  hypoxanthin,  sarcin,  pigment,  etc.;  and  chlorides,  phosphates, 
sulphates,  with  their  bases,  soda,  potash,  lime,  and  magnesia. 

The  volume  of  urine  passed  in  twenty-four  hours  is  usually  from 
forty  to  fifty  ounces  ;  but  it  may  fall  to  thirty  ounces  or  rise  to  seventy 
without  the  existence  of  disease.  Women  are  believed  to  pass  from 
five  to  ten.  ounces  less  than  men.  The  volume  is  diminished  when  the 
skin  is  acting  freely,  as  in  warm  weather,  and  when  the  bowels  are 
loose  ;  and,  on  the  other  hand,  cold,  constipation,  and  nervous  excite- 
ment, especially  if  it  induce  anxiety  and  fear,  all  tend  to  increase  the 
quantity  secreted. 

Color.  The  color  of  the  urine  is  due  largely  but  not  wholly  to 
urobilin,  which  is  formed  from  the  hfematin  of  the  blood.  The  color 
deepens  when  the  urine  is  concentrated,  which  occurs  after  a  hearty 
meal,  or  exercise,  especially  in  warm  weather;  and  it  becomes  paler 
when  a  large  quantity  is  passed.  The  color  is  frequently  changed  in 
disease.  In  fevers  the  urine,  soon  after  being  passed,  is  apt  to  become 
turbid  from  the  precipitation  of  urates,  and  the  color  varies  from  white, 
especially  in  children,  to  yellow,  brown,  or  pink.  When  the  precipi- 
tate settles  the  supernatant  urine  may  be  high-colored  and  clear,  or 
slightly  opaque  from  some  suspended  matter. 

The  admixture  of  pus  and  chyle  gives  the  urine  a  milky  color.  The 
urine  may  also  be  yellowish- white  and  turbid  from  phosphates,  semen, 
sarcinae,  and  bacteria. 

The  urine  is  red,  reddish-brown,  or  "smoky"  in  acute  nephritis, 
the  color  being  due  to  blood.  It  is  bloody  in  haeniaturia,  cancer  of 
the  kidneys  and  bladder,  and  in  injuries  of  the  genito-urinary  appa- 
ratus. The  urine  is  very  red  and  clear  when  concentrated  and  con- 
taining a  large  amount  of  urates.  The  red  color  of  the  urine  may  be 
due  to  haemoglobin,  constituting  hemoglobinuria,  or  to  excess  of  uro- 
bilin, as  in  scurvy  and  pernicious  anaemia.  Haemoglobinuria  occurs 
as  the  result  of  the  action  of  certain  poisons,  such  as  chlorate  of 
potash  ;  in  infectious  diseases,  such  as  scarlet  fever;  and  in  malarial 
fevers;  also  in  a  peculiar  disease  known  as  paroxysmal  haemoglobin- 
uria. 

Again,  a  golden-red  discoloration  of  the  urine  is  common  in  jaun- 
dice ;  frequently  the  upper  layers  have  a  greenish  tinge  by  reflected 
light. 

Finally,  a  red  color  is  produced  by  the  internal  administration  of 
logwood  and  fuchsin. 

A  yellow  color,  when  opaque,  may  be  due  to  suspended  phosphates 
and  urates.  Urine  is  sometimes  golden  yellow  or  of  a  saffron  color 
in  jaundice,  and  from  the  effects  of  santonin,  picric  acid,  and  rhubarb 


676  SPECIAL  DIAGNOSIS. 

taken  internally.  A  yellow  or  yellowish-white  turbidity  may  be  due 
also  to  a  mixture  of  pus  and  phosphates,  and  sometimes  to  semen, 
sarcinae,  and  bacteria.  The  urine  usually  becomes  more  or  less  opaque 
and  yellow  when  it  has  undergone  alkaline  fermentation.  Such  a 
change  occurs  normally  within  a  longer  or  shorter  time  after  the  urine 
has  been  passed.  It  is  promoted  by  heat  and  exposure  to  air,  and 
retarded  by  cold  and  exclusion  from  air.  If  possible,  the  urine  should 
be  examined  before  this  fermentation  has  occurred.  Pathologically, 
in  cases  of  cystitis,  the  urine  when  passed  is  already  in  alkaline  fermen- 
tation. 

The  urine  is  sometimes  chocolate-brown  when  it  contains  blood  and 
the  blood  has  been  acted  upon  by  the  urine,  producing  rnethaenioglobin. 

Brown,  greenish-brown,  or  black  urine  may  result  from  contained  bile- 
salts  ;  from  indican  •  from  carbolic  acid,  creosote,  and  tar  used  inter-    ' 
nally  and  externally;   from  the  internal  use  of  senna,  and  in  cases 
where  there  are   melanotic  tumors.      Senator  injected   melanin  iuto 
human  beings  and  obtained  in  four  cases  only  a  large  indicanuria. 

Urine  is  pale  usually  in  proportion  as  it  is  copious  in  quantity.  It 
is  paler  in  those  who  are  using  milk  or  vegetable  diet  than  in  those 
who  eat  meats.  Under  the  influence  of  nervous  excitement,  especially 
anxiety  and  the  dread  of  an  approaching  ordeal,  such  as  an  examina- 
tion, an  abnormal  quantity  of  very  pale  urine  is  secreted. 

Pathologically,  pale  urine  is  characteristic  of  diabetes,  chronic 
Bright' s  disease,  and  polyuria.  Such  urine  is  also  secreted  in  hyster- 
ical attacks,  at  the  crises  of  febrile  diseases,  and  in  anaemic  conditions. 

The  Volume  of  Urine  in  Disease.  The  volume  may  be  in- 
creased, diminished,  or  unchanged  in  disease.  It  is  increased  princi- 
pally in  three  diseases — diabetes  mellitus,  diabetes  insipidus,  and  in 
the  middle  period  of  chronic  Bright' s  disease,  especially  the  interstitial 
form.  In  diabetes  mellitus  it  sometimes  exceeds  thirty-two  pints.  It 
may  be  increased  also  in  hypertrophy  of  the  left  ventricle,  which 
induces  greater  pressure  in  the  renal  arteries  as  well  as  in  the  whole 
arterial  system;  and  also  in  cystic  degeneration,  and  in  double  hy- 
dronephrosis. 

The  urine  is  diminished  in  acute  nephritis  and  in  the  final  stages  of 
chronic  nephritis  ;  sometimes,  also,  it  is  diminished  in  the  middle 
period  of  chronic  nephritis  ;  but  usually  it  is  here  increased.  All 
diseases  which  directly  or  indirectly  impair  the  force  of  the  circulation 
lessen  the  secretion  of  the  urine.  Hence  the  quantity  is  diminished 
in  diseases  of  the  heart-muscle  and  in  valvular  diseases  not  fully  com- 
pensated ;  in  emphysema  and  in  chronic  bronchitis.  It  is  lessened 
also  in  cirrhosis  of  the  liver.  In  febrile  diseases  the  urine  is  scanty _- 
and  high-colored,  and  sometimes  it  is  almost  suppressed  (anuria). 

The  urine  is  sometimes  suppressed  in  acute  nephritis,  such  as  follows 
scarlet  fever,  and  in  the  final  stages  of  all  the  organic  affections  of  the 
kidneys — chronic  nephritis,  hydro-  and  pyonephrosis,  etc.  It  may 
result  (1)  from  the  destruction  of  the  secreting  tissue  of  the  kidney 
or  interference  with  its  nervous  or  vascular  supply,  or  (2)  from  mechan- 
ical obstruction  to  the  outflow  of  urine.  To  the  first  class  belong  the 
cases  of  suppression  occurring  in  acute  and  chronic  nephritis,  and  the 


DISEASES  OF  THE  KIDNEYS.  677 

suppression  from  shock  and  collapse,  whether  occurring  in  the  stage  of 
collapse  of  yellow  fever,  cholera,  and  other  grave  febrile  diseases,  or 
from  serious  internal  injuries. 

Such  suppression  sometimes  follows,  also,  slight  operations  on  the 
urethra  (urethral  fever);  or  results  from  the  internal  administration  of 
drugs  the  excretion  of  which  occasions  violent  irritation  of  the  kidney 
— cantharides,  turpentine,  and  even  the  inhalation  of  ether.  Clin- 
ically, suppression  not  due  to  obstruction  is  distinguished  from  the 
obstructive  form  by  the  character  of  the  urine,  which  is  usually  not 
entirely  suppressed,  and  by  the  more  rapid  course  of  the  disease.  The 
urine,  according  to  .Roberts,  is  either  concentrated  or  it  contains  albu- 
min, blood,  and  casts.  Death  or  recovery  results  within  a  day  or  two. 
In  the  obstructive  form,  on  the  other  hand,  the  urine  which  escapes 
past  the  obstacle  is  pale,  watery,  and  devoid  of  albumin  and  casts. 

Obstructive  suppression  is  the  result  of  the  plugging  of  the  ureter 
by  a  calculus,  when  the  opposite  kidney  is  either  absent  or  incapable 
of  secreting.  It  also  results  from  the  occlusion  of  the  ureters  by  mor- 
bid growths,  especially  at  the  vesical  orifices,  from  lateral  pressure 
upon  the  ureters,  or  from  some  interference  or  malformation  of  the 
ureters  or  renal  arteries. 

Acute  transient  obstructive  suppression  occurs  sometimes  in  persons 
with  enlarged  prostates,  or  old  strictures,  who  have  drunk  too  freely 
of  alcoholic  beverages  and,  perhaps,  have  wound  up  a  debauch  by 
sexual  intercourse. 

The  Density  of  the  Urine.  The  average  density  of  normal  urine 
is  about  1020.  It  may  fall  to  1015  or  rise  to  1025,  depending  upon 
the  quantity  of  fluid  and  food  taken,  the  condition  of  the  atmosphere, 
especially  as  regards  temperature,  and  upon  mental  influences  usually 
of  an  emotional  character.  The  specific  gravity  of  the  urine  is  tested  by 
a  urinometer  graduated  for  degrees  of  density  between  1000  and  1040. 
Only  a  reliable  instrument  should  be  used.  As  the  density  of  the 
urine  passed  at  different  times  during  the  day  varies  greatly,  the  urine 
for  the  whole  twenty-four  hours  should  be  saved  and  a  specimen  of 
this  tested. 

The  method  of  taking  the  specific  gravity  is  very  simple.  A  test- 
tube  or  graduate,  having  a  diameter  of  about  one  and  a  quarter  inches 
and  a  length  of  six  or  seven  inches,  is  filled  with  urine  to  such  a  point 
that  the  lowest  part  of  the  urinometer  when  inserted  floats  clear  of  the 
bottom  of  the  tube.  The  instrument  must  also  float  free  of  the  sides 
of  the  tube.  The  specific  gravity  should  then  be  read  off  from  be- 
low, that  is  to  say,  by  holding  the  tube  up  so  that  the  level  of  the 
fluid  is  a  little  above  that  of  the  eye.  Most  urinometers  are  graduated 
for  60°,  but  in  ordinary  examinations  it  is  not  necessary  to  have  the 
urine  exactly  at  this  temperature;  it  should,  however,  be  allowed  to 
cool  after  it  has  been  passed,  otherwise  the  specific  gravity  will  appear 
to  be  too  low. 

In  disease  the  specific  gravity  varies  more  widely  than  in  health; 
it  may  fall  to  1000  or  1005  in  diabetes  insipidus  and  chronic  Bright' s 
disease,  and  rise  to  1060  or  even  higher  in  diabetes  mellitus.  As  a 
rule,  to  which  the  urine  in  diabetes  mellitus  is  the  principal  exception, 


678  SPECIAL  DIAGNOSIS. 

the  color  is  an  index  of  the  density,  pale  urine  being  of  low  density 
and^high-colored  urine  of  high  density. 

The  density  is  increased  when  the  urine  is  scanty  in  amount,  whether 
as  the  result  of  fever,  acute  nephritis,  large  consumption  of  solid  food, 
exercise,  or  free  sweating.  In  all  such  cases  the  specific  gravity  rarely 
rises^above  1035,  and  usually  not  above  1028  or  1030.  When  the 
specific  gravity  rises  above  1035,  and  the  urine  is  pale  in  color,  the 
presence  of  sugar  is  to  be  suspected  ;  and  when  it  rises  above  1040 
sugar  is  almost  certainly  present. 

The  specific  gravity  is  lowered  by  drinking  copiously,  by  the  effect 
of  external  cold,  by  a  diet  of  vegetables  and  milk,  and,  iu  general, 
by  the  same  causes  that  make  the  urine  copious.  Usually,  but  not 
always,  a  urine  containing  a  large  amount  of  albumin  is  of  low  density. 

Pathologically,  a  low  specific  gravity  is  encountered  in  diabetes 
insipidus,  in  which  it  may  fall  nearly  or  quite  to  1000;  generally  in 
the  middle  or  quiescent  period  of  chronic  Bright' s  disease;  in  the  crisis 
of  fevers;  in  obstructive  suppression;  in  hysterical  attacks,  and  in 
hydronephrosis. 

Specific  Gravity  as  an  Index  of  the  Amount  of  Solids.  If  the  last 
two  figures  of  the  specific  gravity  be  doubled,  the  sum  will  represent 
the  amount  of  solid  matter  in  1000  grains  of  urine.  This  is  Trapp's 
method;  the  estimate  is  only  rough,  but  it  is  useful.  Of  course,  the 
urine  for  twenty-four  hours  must  be  used. 

Reaction.  The  reaction  of  healthy  urine  is  usually  acid,  but  it 
may  be  neutral  or  slightly  alkaline  about  two  hours  after  a  meal  of 
mixed  food.  The  acidity  is  tested  with  litmus-paper;  the  blue  paper 
is  turned  purple  or  red  by  an  acid,  and  the  red  paper  is  turned  blue 
by  an  alkali.  Violet  paper  is  to  be  preferred,  as  it  is  suitable  for 
showing  both  reactions,  an  alkali  turning  it  blue  and  an  acid  red. 

The  acidity  of  the  urine  is  increased  in  gout,  lithiasis,  acute  rheu- 
matism, diabetes,  chronic  Bright' s  disease,  and  as  the  result  of  the 
administration  of  vegetable  or  mineral  acids. 

The  urine  is  alkaline  as  the  result  of  alkaline  fermentation  in  the 
bladder  in  cystitis;  from  the  presence  of  much  blood  or  pus;  from  pro- 
longed immersion  of  the  body  in  a  cold  bath ;  in  debilitating  diseases 
and  in  some  cases  of  nervous  dyspepsia,  and  as  the  result  of  the  inter- 
nal administration  of  alkalies. 

Urinary  Sediments.  A  white  flocculent  sediment,  composed  of 
epithelium  and  mucus,  occurs  normally  in  most  urines  after  they  have 
stood  for  some  hours. 

A  dense  sediment,  varying  in  color  from  that  of  brown  sugar  to 
pink  or  red,  consists  of  amorphous  urates.  It  dissolves  upon  the  appli- 
cation of  heat.  A  sediment  usually  resembling  red  pepper,  but  some- 
times of  a  brown  color,  consists  of  uric  acid.  It  can  be  proved  to  be 
uric  acid  by  the  murexid  test.  The  suspected  material  is  placed  in  a 
crucible  or  evaporating  dish  with  a  few  drops  of  nitric  acid.  As  heat 
is  applied  the  uric  acid  or  amorphous  urate  dissolves  with  effervescence. 
Heat  is  now  kept  up  until  the  material  is  evaporated  to  dryness;  it  is 
then  allowed  to  cool.  If  it  is  now  touched  with  a  glass  rod,  dipped 
in  strong  ammonia,  a  characteristic  blue  or  violet  color  is  produced. 


DISEASES  OF  THE  KIDNEYS.  679 

Uric  acid  is  not  usually  so  abundant  as  the  sediment  of  amorphous 
urates;  it  siuks  more  rapidly,  and  is  deposited  from  acid,  high-colored 
urines. 

A  yellowish  or  whitish  sediment  may  consist  of  urate  of  sodium. 

A  white  sediment  usually  consists  of  phosphates,  associated  with 
which  we  sometimes  find  a  white  sediment  consisting  of  urate  of  am- 
monium, with  or  without  jdus.  Such  urines  are  alkaline.  A  white 
sediment  may  be  due  to  uric  acid,  especially  in  children. 

A  yellowish-white  sediment  may  consist  of  pus,  with  or  without 
mucus.  If  the  urine  is  acid,  the  sediment  is  loose  and  free  to  move; 
but  when  the  urine  is  alkaline  the  sediment  consists  of  a  viscid,  coher- 
ent mass,  which  can  be  drawn  out  into  tough,  stringy  filaments. 

A  chocolate-brown  sediment,  occurring  in  a  reddish,  smoky  urine, 
consists  of  blood  from  the  kidneys.  Clots  of  blood  come  from  the 
ureters,  bladder,  or  urethra. 

Odor.  The  odor  of  normal  urine  is  sometimes  spoken  of  as  aro- 
matic, but  generally  it  is  sufficiently  characteristic  to  be  best  described 
as  urinous.  When  the  urine  is  concentrated  the  odor  is  intensified, 
and  may  become  unpleasantly  strong,  like  the  urine  of  the  horse. 

Certain  articles  of  food,  such  as  garlic  and  asparagus,  give  the 
urine  characteristic  odors.  Turpentine,  both  when  taken  internally 
and  inhaled,  gives  to  it  the  odor  of  violets.  The  odors  of  copaiba  and 
of  cubebs  can  easily  be  detected  in  the  urine  of  patients  who  are  taking 
these  drugs. 

In  marked  cystitis  the  natural  urinous  odor  becomes  more  pungent, 
and  is  blended  with  a  strong  ammoniacal  odor.  When  much  pus  is 
present,  and  the  urine  has  stood  awhile,  a  putrid  odor  is  developed. 

In  diabetes  mellitus  the  urine  has  a  sweetish,  hay-like  odor.  In 
diabetic  coma  the  odor  is  sometimes  that  of  chloroform,  due  to  the  pres- 
ence of  acetone  and  diaceticacid  in  the  urine.  This  odor,  however,  is 
more  likely  to  be  detected  in  the  breath. 

2.  Chemical  Examination  of  the  Urine.  Examination  of  the 
urine  by  the  unaided  senses,  which  has  been  dwelt  upon  thus  far,  is 
simply  preliminary  to  an  examination  by  chemical  methods  and  by 
instruments  of  precision,  particularly  the  microscope. 

Urea.  Urea  is  freely  soluble  in  water,  and  hence  never  appears 
as  a  sediment.  It  is  the  most  important  final  product  of  nitrogenous 
disintegration  in  the  body,  and  is  an  index  of  the  eliminative  power  of 
the  kidneys  Usually  the  density  of  the  urine  increases  in  proportion  to 
the  amount  of  urea  contained  in.it.  The  average  daily  amount  of  urea 
excreted  by  an  adult  man  between  the  ages  of  twenty  and  forty  years 
is  about  500  grains.  The  urea,  like  the  total  volume  of  the  urine,  is 
subject  to  variations  within  the  limits  of  health.  It  is  increased  after 
a  meal,  especially  if  the  latter  be  rich  in  nitrogenous  food  ;  after 
copious  infusion  of  liquids,  and  by  a  close  atmosphere.  On  the  other 
hand,  fasting,  free  perspiration,  a  loose  condition  of  the  bowels,  and 
a  vegetable  or  milk  diet  diminish  the  quantity  of  urea.  Again,  the 
quantity  varies  with  the  age  of  the  person.     According  to  Ralfe,  at 


680  SPECIAL  DIAGNOSIS. 

five  years  the  amount  daily  is  180  grains;  at  12,  320;  at  21,  535; 
and  at  40  years,  555  grains. 

A  large  man  will  excrete  absolutely  more  than  a  small  man,  and  a 
large,  muscular  man  will  excrete  relatively  more  than  a  fat  man  of  the 
same  height. 

The  excretion  of  urea  is  increased  in  fever  and  inflammatory  dis- 
eases; in  diabetes  mellitus  and  insipidus;  in  malaria,  pernicious  anae- 
mia, and  after  a  crisis  in  pneumonia.  It  is  increased  also  by  certain 
beverages,  as  coffee,  and  by  many  drugs,  especially  those  which  act  as 
hepatic  stimulants. 

It  is  diminished  in  all  forms  of  nephritis,  especially  when  uraemia 
results  ;  in  acute  gout  and  chronic  rheumatism;  in  diseases  accompanied 
by  emaciation  and  cachexia;  and  in  leprosy,  pemphigus,  melancholia, 
imbecility,  catalepsy,  hysteria,  and  cholera  (Saundby). 

Estimation  of  Urea.  For  the  methods  employed  in  the  exact  quan- 
titative estimation  of  urea  the  student  is  referred  to  special  works  on 
the  urine. 

For  ordinary  clinical  purposes  the  apparatus  devised  by  Professor 
Charles  Doremus,  and  known  as  his  ureometer,  gives  sufficiently  accu- 
rate results.  The  principle  upon  which  it  is  based  is  that  urea  when 
brought  in  contact  with  sodium  hypobrornite  is  decomposed,  and  free 
nitrogen  is  eliminated.  The  nitrogen  evolved  is  the  measure  of  the 
urea  contained  in  the  urine.  The  instruments  are  graduated  so  that 
each  division  of  the  scale  represents  one  grain  of  urea  per  fluidounce 
of  nirine. 

The  hypobrornite  solution  is  prepared  by  dissolving  100  grammes  of 
sodium  hydroxide  in  250  c.c.  of  water,  cooling  the  solution,  and  then 
adding  25  c.c.  of  bromine 

It  is  better,  however,  to  freshly  prepare  the  hypobrornite  solution 
for  each  examination.  This  can  readily  be  done  by  having  a  solution 
of  sodium  hydroxide  containing  six  ounces  to  a  pint  of  water.  It 
should  be  kept  tightly  corked  with  a  rubber  or  paraffined  stopper.  The 
sodium  hydroxide  solution  is  poured  into  the  long  tube  of  the  ure- 
ometer to  the  mark  =,  then  one-tenth  of  its  volume  of  bromine  is 
introduced  by  means  of  a  pipette,  and  sufficient  water  added  to  fill  the 
long  arm  and  the  bend  of  the  tube.  The  hypobrornite  solution  should 
fill  the  tube  completely,  and  any  bubbles  rising  to  the  top  of  the 
tube  should  be  removed  before  the  introduction  of  the  urine.  The 
pipette  is  then  filled  with  the  urine  up  to  the  1  c.c.  mark,  any  urine 
adhering  to  its  surface  being  carefully  wiped  off.  The  pipette  is  in- 
troduced carefully  so  as  not  to  compress  the  bulb  until  the  point  ex- 
tends as  high  up  as  possible  beyond  the  bend.  The  bulb  is  now 
compressed  slowly  until  1  c.c.  of  urine  has  been  introduced.  Decom- 
position of  the  urea  occurs  and  bubbles  of  nitrogen  rise  to  the  surface 
of  the  long  arm  of  the  tube ;  when  bubbles  of  gas  cease  to  be  evolved 
the  volume  of  nitrogen  gas  is  read  off,  and  according  to  the  gradua- 
tions on  the  tube  considered  as  so  many  grains  of  urea  per  fluidounce 
of  urine,  or  as  so  many  milligrammes  of  urea  in  1  c.c.  of  urine,  ac- 
cording to  whether  it  is  graduated  in  the  English  or  the  metric 
system. 


DISEASES  OF  THE  KIDNEYS.  681 

Detection  and  Estimation  of  the  Chlorides.  The  presence  or 
absence  of  chlorides  is  sometimes  of  diagnostic  value.  They  are 
increased  when  absorption  of  exudations  or  transudations  is  going  on, 
and  in  malarial  fevers,  diabetes  insipidus,  and  Bright' s  disease.  They 
are  diminished  or  absent  in  pneumonia  during  its  progressive  stage, 
and  in  fevers.  The  chlorine  of  the  chlorides  can  be  detected  and 
roughly  estimated  by  an  8  or  10  per  cent,  solution  of  argentic  nitrate. 
A  few  drops  of  nitric  acid  are  first  added  to  the  urine  to  prevent  the 
silver  from  precipitating  phosphoric  acid.  A  single  drop  of  the  silver 
solution  mentioned  will  precipitate  the  chlorine  of  the  chlorides  in  a 
thick  white  lump,  which  falls  to  the  bottom  of  the  test-tube,  provided 
the  amount  present  is  normal.  If,  on  the  other  hand,  the  quantity  is 
diminished  to  one-tenth  per  cent,  or  less,  it  will  not  be  precipitated  in 
a  lump  or  lumps,  but  a  white  cloudiness  is  produced  which  renders  the 
whole  solution  opaque.  If  no  precipitation  or  cloudiness  occurs,  the 
chlorides  are  absent. 

Detection  and  Estimation  of  Serum-albumin.  Albumin  is  a 
very  common,  but  cannot  be  looked  upon  as  a  normal  constituent  of 
the  urine,  though  its  presence  by  no  means  indicates  disease  of  the 
kidneys.  The  ordinary  form  is  serum-albumin,  but  other  proteids, 
as  globulin,  mucin,  peptone,  albumose,  haemoglobin,  fibrin,  and  met- 
hremoglobin  are  found  at  times.  The  most  trustworthy  tests  for  ordi- 
nary albumin  (serum-albumin)  are:  boiling,  with  the  addition  of  nitric 
or  acetic  acid;  overlaying  cold  nitric  acid  with  urine  (Heller's  test); 
the  picric  acid,  the  potassium  ferrocyanide,  and  the  potassium- 
mercuric-iodide  (Tan ret' s)  tests.  The  author  believes  that  many  of 
the  recent  tests,  such  as  sodium  tungstate,  acidulated  brine,  mag- 
nesium nitrate,  phenic-acetic  acid,  and  trichloracetic  acid,  are  too 
sensitive  and  precipitate  other  substances  in  the  urine,  and,  therefore, 
are  not  reliable  for  clinical  work. 

Boiling  and  Nitric  Acid  Test.  A  narrow,  long  test-tube  is  filled 
two-thirds  full  of  urine  and  the  upper  third  boiled  thoroughly,  and 
then  a  few  drops  of  nitric  acid  are  added.  Any  albumin  present  will 
be  coagulated  and  appear  as  a  white  cloud,  contrasting  strongly  with 
the  clear  unboiled  urine  beneath  it.  When  the  albumin  is  moderate 
or  even  small  in  amount  it  can  be  detected  without  difficulty  by  simply 
holding  the  test-tube  up  to  the  light.  When  there  is  only  a  faint  trace 
present  it  will  be  overlooked  unless  the  tube  be  examined  against  a 
dark  surface  in  such  a  way  that  the  light  falls  upon  it  from  above,  in 
front,  and  pr^fnrably  a  little  to  one  side.  A  cloud  may  escape  detection 
when  looked  for  by  artificial  light,  but  may  be  distinct  by  daylight. 
Serum-globulin  is  also  precipitated  by  this  test.  But  serum-globulin 
is  not  often  present  by  itself,  and  its  significance  is  not  yet  under- 
stood. It  may  be  detected  in  any  urine,  as  Roberts  points  out,  by 
diluting  the  urine  with  pure  water,  the  urine  then  becoming  more  or 
less  milky.  It  may  be  removed  from  urine  by  saturating  the  latter 
with  magnesium  sulphate  and  filtering  off  the  precipitated  globulin. 
The  presence  of  serum-globulin  in  no  way  interferes  with  the  test  for 
serum-albumin. 

If  the  urine  is  opaque  from  amorphous  urates,  it  is  unnecessary  to 


682  SPECIAL  DIAGNOSIS. 

filter  them  out;  heat  much  below  boiling  will  dissolve  them,  the  pre- 
cipitation of  albumin  occurring  later  at  a  higher  temperature. 

If  the  urine  is  alkaline  or  faintly  acid,  phosphates  will  produce  a 
cloud  upon  heating  the  urine;  but  they  are  instantly  dissolved  upon 
the  addition  of  a  few  drops  of  nitric  or  acetic  acid. 

Mucin  produces  an  opalescence  upon  heating  with  an  organic  acid, 
but  Saundby  declares  that  it  coagulates  not  in  flocculi,  as  is  the  case 
with  albumin,  but  in  the  form  of  tiny  filaments. 

Boiling  and  Acetic  Acid  Test.  This  is  preferred  by  many  to  the  pre- 
ceding test.  It  is  performed  in  a  similar  manner.  ■  Acetic  acid  is, 
however,  not  reliable  for  acidulation:  it  precipitates  the  mucin  which 
is  often  found  in  healthy  urine,  forming  a  white  cloud  which  is  apt  to 
be  mistaken  for  albumin;  this  is  especially  true  in  urines  of  high 
specific  gravity  containing  uric  acid,  urates,  or  oxalates. 

The  Nitric  Acid  [Heller's)  Test.  This  test,  while  not  so  delicate  as 
the  acetic  acid  test,  is  very  simple  and  accurate  in  its  results.  Cold 
nitric  acid  is  poured  into  a  test-tube  to  the  depth  of  about  an  inch. 
The  tube  is  then  inclined  to  an  angle  of  about  45  degrees,  and  urine 
allowed  to  flow  gently  down  upon  the  acid  by  trickling  along  the  side 
of  the  tube  from  a  pipette  or  glass  tube.  At  the  point  of  contact  of 
the  acid  and  urine  a  zone  of  white  coagulated  albumin  forms.  The 
test  can  also  be  made  as  follows :  Into  a  short,  broad  test-tube  several 
cubic  centimetres  of  urine  are  poured;  nitric  acid  is  introduced  with  a 
pipette  provided  with  a  rubber  bulb  by  passing  the  pipette  through  the 
urine  to  the  bottom  of  the  tube  and  gently  pressing  the  rubber  bulb; 
care  must  be  taken  to  withdraw  the  pipette  as  the  last  portion  of  ^.cid 
is  expelled,  so  that  no  air-bubbles  will  break  up  the  point  of  contact  of 
the  urine  and  acid.  The  thickness  of  the  white  zone  is  generally  an 
index  of  the  amount  of  albumin  present.  If  there  is  barely  a  trace 
of  albumin,  half  an  hour  may  be  required  to  develop  any  opalescence. 

A  cloud  of  urates  is  sometimes  produced  and  obscures  the  test, 
This  cloud  does  not,  however,  begin  at  the  point  of  contact  and  extend 
upward,  but  at  the  upper  level  of  the  urine  and  extends  downward, 
and  is  dissipated  by  heat. 

Patients  who  are  taking  copaiba  or  cubebs  pass  a  urine  which  gives 
a  white  zone  at  the  point  of  contact  with  cold  nitric  acid,  but  heat 
diminishes  the  opacity,  and  the  odor  of  the  drugs  in  the  urine  assists 
in  the  detection  of  their  presence. 

The  Picric  Acid  Test.  This  is  an  extremely  delicate  test  for  albu- 
min. A  saturated  solution  of  picric  acid  is  allowed  to  flow  down  upon 
and  slightly  mix  with  the  upper  layers  of  the  urine,  which  half  fills  a 
good-sized  test-tube.  At  the  point  of  contact  an  opaque  white  zone  of 
coagulated  albumin  is  formed.  If  no  white  zone  appears,  albumin  is 
almost  certainly  absent.  Hence,  the  picric  acid  test  is  a  valuable 
negative  test.  But,  unfortunately,  a  Avhite  zone  is  formed  by  pep- 
tone, mucin,  and  various  alkaloids,  particularly  quinine.  The  white 
zone  produced  by  the  presence  of  the  substances  just  named  disappears 
upon  the  application  of  heat,  whereas  an  opalescence  due  to  albumin 
becomes  diffused  throughout  the  whole  urine. 

The  Potassium  Ferrocyanide  Test.     This  test  is  highly  recommended 


DISEASES  OF  THE  KIDNEYS.  683 

as  simple,  rapid,  and  accurate  by  Purdy,  who  performs  it  as  follows  : 
Into  a  test-tube  are  poured  fifteen  to  thirty  drops  of  acetic  acid,  and 
then  two  or  three  times  that  amount  of  potassium  ferrocyanide  solution 
(1  to  20)  is  added,  and  the  two  thoroughly  mixed  by  shaking  the  tube. 
The  urine  is  now  added  to  the  depth  of  two-thirds  of  the  test-tube. 
If  any  albumin  is  present,  it  will  be  precipitated  throughout  the  whole 
volume  of  urine  in  the  form  of  a  milk-like  flocculent  cloud,  more  or 
less  according  to  the  amount  of  albumin  present.  By  this  method  all 
modifications  of  albumin,  acid  or  alkaline,  are  precipitated  and  the 
precipitation  of  mucin  is  avoided.  It  gives  no  reaction  with  phos- 
phates, urates,  peptones,  vegetable  alkaloids,  or  the  acids  found^  in 
the  urine  after  the  ingestion  of  copaiba,  etc.  This  test  may  also  be 
performed  as  follows  :  An  ordinary  test-tube  is  half-filled  with  urine 
and  a  drachm  or  two  of  the  potassium  ferrocyanide  solution  (1  to  20) 
are  added.  After  thoroughly  mingling  the  reagent  and  the  urine  a  few 
drops  of  acetic  acid  are  added.  If  albumin  is  present,  it  will  plainly 
come  into  view.  This  test,  therefore,  depends  upon  the  production  of 
a  cloudiness  or  milkiness  throughout  the  entire  mixture  in  the  tube. 
To  some  eyes  the  albumin  is  not  so  readily  perceived  as  in  those 
tests  which  depend  upon  the  formation  of  a  distinct  line  at  the  point 
of  contact. 

The  Potassium-mercurie  Iodide  Test  (Tanret's).  The  solution  is  made 
as  follows  :  Potassium  iodide,  3.32  grammes ;  bichloride  of  mercury, 
1.35  grammes;  acetic  acid,  20  c.c;  distilled  water  about  30  c.c.  (the 
potassium  iodide  and  the  bichloride  of  mercury  should  be  dissolved 
separately  in  the  water  and  the  solution  mixed,  to  which  the  acetic 
acid  is  added  and  the  whole  made  up  to  60  c.c.  with  distilled  water). 
As  thus  prepared  the  test  is  applied  by  the  contact-method  by  over- 
laying the  reagent  with  urine.  This  test  responds  to  all  modifications 
of  albumin,  also  to  peptones  and  proteoses,  as  well  as  to  the  vege- 
table alkaloids  and  acids  found  in  the  urine  after  the  ingestion  of 
copaiba,  etc.  All  reactions  except  those  occurring  with  albumin, 
mucin,  and  the  acids  found  in  the  urine  after  the  ingestion  of  copaiba, 
etc.,  disappear  with  heat.  It  is  a  very  good  and  delicate  control-test 
for  albumin.  The  solution,  however,  is  of  a  yellowish  hue,  quite 
similar  to  the  color  of  urines  of  low  specific  gravity.  This  some- 
times renders  the  line  of  contact  difficult  to  perceive. 

It  is  well  to  follow  a  routine  method  in  testing  for  albumin  :  first, 
by  boiling  and  the  addition  of  nitric  acid,  and  then  the  contact 
(Heller's)  test;  if  there  is  doubt,  either  the  potassium  ferrocyanide 
or  picric  acid  test;  finally,  Tanret's  solution  will  reveal  minute  quan- 
tities of  albumin,  and  may  be  used  as  a  confirmatory  test. 

In  all  the  tests  for  albumin  mentioned  a  clear  urine  is  necessary, 
especially  when  the  amount  of  albumin  is  very  small.  This  can  be 
obtained  by  filtration  when  the  opacity  is  due  to  pus,  blood,  mucus, 
and  uric  acid  ;  and,  more  effectively,  by  the  addition  of  a  small  quan- 
tity of  sodium  hydroxide,  warming  slightly,  and  filtering.  If  the 
filtrate  is  not  clear,  a  few  drops  of  magnesian  fluid  (sulphate  of 
magnesium,  pure  ammonium  chloride,  and  pure  liquor  ammonia?,  of  each 
2  drachms  ;  distilled  water,  2  ounces),  as  recommended  by  Hoffmann 


684 


SPECIAL  DIAGNOSIS. 


Fig.  11.8. 


and  Ultzmann,    may   be    added,    and   the   urine    again   warmed  and 
filtered. 

The  quantitative  estimation  of  albumin  is  of  some  importance.  The 
most  direct  method  is  by  coagulating  the  albumin  by  boiling,  collect- 
ing it  upon  a  weighed  filter,  washing  with  water  and  finally  with 
alcohol,  drying,  and  weighing  it.  Such  a  process,  how- 
ever, consumes  too  much  time  for  clinical  purposes,  and 
it  is  not  faultless.  An  approximate  estimation  may  be 
made  by  boiling  the  urine  in  a  test-tube,  adding  several 
drops  of  nitric  acid,  allowing  the  albumin  to  settle,  and 
then  comparing  the  depth  of  albumin  with  the  height 
of  the  column  of  urine.  In  this  way  we  may  speak  of 
urine  furnishing  one-tenth  or  one-quarter  of  its  bulk  of 
coagulated  albumin. 

Esbach  has  invented  an  albuminimeter  (Fig.  118) 
which  gives  good  results.  The  solution  used  to  pre- 
cipitate the  albumin  consists  of  10  grammes  of  picric 
acid  and  20  grammes  of  citric  acid,  chemically  pure  and 
dry,  dissolved  in  900  c.c.  of  hot  water;  and  after  cooling, 
diluting  the  solution  to  1000  c.c.  The  urine  is  diluted 
with  a  definite  amount  of  water  if  it  contains  too  much 
albumin.  The  albuminimeter  is  filled  to  the  mark  U 
with  urine,  and  from  that  mark  to  R  with  the  reagent. 
The  tube  is  then  corked  with  a  rubber  stopper,  turned 
upside  down  ten  times,  so  as  to  mix  the  urine  intimately 
with  the  reagent,  and  then  allowed  to  stand  undisturbed 
for  twenty-four  hours.  At  the  end  of  this  time  the 
depth  of  the  sediment  of  coagulated  albumin  is  ascer- 
tained by  observing  where  the  top  of  the  sediment  comes 
in  "contact  with  a  mark  on  the  scale  on  the  tube.  Each 
mark  corresponds  to  one-tenth  per  cent,  of  albumin. 

This  estimation,  as  already  stated,  is  not  absolutely 
accurate.  Nevertheless,  if  used  systematically,  and 
always  in  the  same  way,  relative  values  will  be  obtained, 
and  these  are  the  most  important  in  watching  the  prog- 
ress of  a  case,  as  they  give  positive  information  regard- 
ing an  increase  or  diminution  of  the  amount  of  albumin 
in  the  urine.     It  scarcely  need    be  said  that  the  urine 

Esbacn's  -  J 

albuminimeter.  tested  must  be  a  portion  of  the  whole  twenty-four  hours 
urine. 

The  estimation  of  the  amount  of  albumin  is  also  readily  made  with 
the  centrifugal  machine-  to  10  c.c.  of  the  albuminous  urine  are  added 
3.5  c.c.  of  potassium  ferrocyanide  solution  (1  to  10)  and  1.5  c.c.  of 
acetic  acid;  the  mixture  is  then  revolved  in  the  machine  about  three 
minutes,  and  the  amount  of  precipitate  read  off. 

Albuminuria.  Albuminuria  is  not  indicative  of  disease  of  any 
one  organ,  nor  does  it  point  to  any  general  pathological  condition.  It 
occurs  as  follows  : 

1.  In  diseases  of  the  kidney:  acute  and  chronic  Blight's  disease, 
amyloid  disease,  tubercle,  cancer,  abscess,  and  calculus. 


If 


DISEASES  OF  THE  KIDNEYS.  685 

2.  In  disturbances  of  the  circulation;  diseases  of  the  heart  and 
chronic  pulmonary  diseases,  as  emphysema ;  obstruction  of  the  renal 
arteries  or  veins,  cirrhosis  of  the  liver,  peritonitis,  pregnancy,  abdom- 
inal tumors;  in  passive  congestions  due  to  great  weakness;  in  anaemia 
and  Graves'  disease. 

3.  In  febrile  and  inflammatory  diseases  :  in  the  eruptive  and  infec- 
tious fevers,  and  in  rheumatism,  diphtheria,  pneumonia,  and  gout. 

4.  In  blood  diseases  :  purpura,  leucocythseinia,  and  scurvy. 

5.  From  the  poisonous  action  of  drugs  :  lead,  turpentine,  and  others. 

6.  In  nervous  disorders  :  concussion  of  the  brain  and  cerebral  hem- 
orrhage, epilepsy,  tetanus,  and  delirium  tremens;  as  Pye-Smith  re- 
marks, it  is  doubtful  whether  albuminuria  is  caused  by  the  nervous 
diseases. 

7.  Local  extra-renal  affections:  pyelitis,  cystitis,  gonorrhoea,  and 
leucorrhoea. 

8.  Functional.  In  young  persons,  particularly  of  the  male  sex, 
there  occurs  occasionally  slight  albuminuria  after  exercise,  a  special 
diet,  or  a  cold  bath.  Albumin  may  be  found  after  rising  in  the  morn- 
ing, or  early  after  dinner,  or  toward  evening.  On  account  of  its 
occurring  only  at  certain  times  it  has  been  called  "  cyclical "  or 
"  intermittent,"  and  because  there  is  no  evident  disease  present  it  is 
occasionally  spoken  of  as  "  physiological"  albuminuria. 

Goodhart  examined  the  urine  of  1500  individuals  and  noted  albu- 
min in  272,  or  in  20  per  cent.  In  39  cases  the  albuminuria  could  not 
positively  be  said  to  be  due  to  disease  of  the  kidney.  Of  these  39, 
26  were  males  and  13  females.  In  32  of  the  39  cases  it  was  tem- 
porary, and  in  most  of  them  it  had  disappeared  within  forty-eight 
hours,  or  sooner.  In  2  cases  there  Avere  oxalates  in  the  urine  ;  in  1 
hemoglobinuria;  in  8  leucorrhoeal  discharges  and  discharges  from 
other  parts  of  the  genital  passages  (see  division  7);  and  in  17  a  mark- 
edly neurotic  temperament.  These  last  he  thinks  the  most  typical 
cases  of  intermittent  albuminuria;  on  the  whole,  he  regards  the  con- 
dition as  less  common  than  has  been  supposed. 

One  variety  of  functional  albuminuria  is  apparently  due  to  the  irri- 
tation of  the  kidney  produced  by  the  excretion  of  oxalates  and  uric  acid. 
The  urine  is  of  increased  density,  1028,  1030,  or  higher,  and  contains 
uric  acid  or  oxalate  of  lime,  or  both,  and  cylindroids.  Tube-casts  are 
very  uncommon.  The  albuminuria  usually  disappears  under  proper 
diet.     This  condition  is  sometimes  called  "  morbus  Da  Costse." 

It  is  conceded  that  there  may  be  albuminuria  of  renal  origin  without 
renal  disease,  but  the  diagnosis  must  be  by  exclusion,  and  can  be 
reached  safely  only  after  extended  observation.  The  most  important 
elements  in  the  diagnosis  are  :  the  age  of  the  patient,  unimpaired  gen- 
eral health,  a  specific  gravity  of  the  urine  normal  or  above  normal,  the 
fact  that  the  albuminuria  is  influenced  by  diet  and  exercise,  and  that 
it  tends  to  disappear  under  suitable  regimen.  The  prognosis  is  favor- 
able. 

Peptone.  Peptone  occurs  in  the  urine  in  a  variety  of  conditions, 
and  hence  not  much  diagnostic  value  can  be  attached  to  its  detection. 
According  to  Von  Jaksch,  its  presence  may  indicate  that  a  suppurative 


686  SPECIAL  DIAGNOSIS. 

process  exists.  When  the  diagnosis  lies  between  epidemic  cerebro- 
spinal meningitis  and  tubercular  meningitis  the  presence  of  peptonuria 
speaks  for  the  former,  but  only  when  ulcerative  processes  in  other 
organs,  especially  in  the  lungs,  exist,  can  with  certainty  be  excluded. 
Exact  tests  for  its  detection  are  too  elaborate  for  clinical  purposes.  The 
late  Dr.  N.  A.  Randolph  suggested  the  following  test,  which  is  given 
by  Tyson:  To  5  c.c.  of  urine,  which  must  be  cold  and  faintly  acid,  add 
two  drops  of  a  saturated  solution  of  potassium  iodide  and  then  three 
or  four  dops  of  Millon's  reagent.  If  peptones  or  bile-acids  are  pres- 
ent, a  yellow  precipitate  falls.  If  the  yellow  precipitate  does  not 
respond  to  the  test  for  bile-acids,  it  is  due  to  peptone. 

Picric  acid,  when  allowed  to  overlay  urine  containing  peptone,  pro- 
duces a  white,  hazy  zone  which,  unlike  albumin,  disappears  upon  the 
application  of  heat.  If  the  patient  has  taken  no  vegetable  alkaloids, 
particularly  quinine,  the  zone  described  may  be  assumed  to  be  due  to 
peptone.      Nitric  acid  and  heat  do  not  precipitate  peptone. 

It  is  probable  that  in  most  of  the  cases  in  which  peptone  is  thought 
to  exist  in  the  urine  albumose  is  responsible  for  the  reaction.  Harris 
(Amer.  Journ.  Med.  Sci.,  May,  1896)  says  that  true  peptone  being 
very  rarely,  if  ever,  found  in  the  urine,  the  term  albumosuria  should 
be  substituted  for  the  term  peptonuria. 

Mucin  (Nucleo-albumin).  Small  quantities  of  mucin  are  present  in 
all  urines,  being  usually  more  abundant  in  women,  from  the  admixture 
of  the  vaginal  secretion.  Mucin  is  increased  in  catarrhal  affections  of 
the  genito-urinary  passages  and  of  the  bladder.  It  is  precipitated  by 
acetic  acid  and  other  organic  acids,  but  not  by  nitric  acid. 

According  to  Roberts,  the  best  method  for  the  detection  of  mucin 
is  by  means  of  a  saturated  solution  of  citric  acid,  employed  in  the 
same  manner  as  the  contact-method  of  applying  the  nitric  acid  test 
for  albumin.  A  small  quantity  of  the  urine  is  first  put  in  a  test-tube, 
and  citric  acid  allowed  to  trickle  down  the  sides  of  the  tube  until  it 
forms  a  distinct  layer  below  the  column  of  urine.  If  mucin  is  present, 
there  will  gradually  appear  an  opalescent  zone  immediately  above  the 
layer  of  acid.  Acetic  acid,  mixed  with  one-third  of  its  volume  of 
glycerin,  answers  admirably  as  a  test  for  mucin.  Sometimes,  when 
mucin  is  very  abundant,  the  addition  of  an  excess  of  acetic  acid  pro- 
duces a  marked  milkiness  in  the  urine,  which  is  not  discharged  by 
boiling  the  liquid. 

Blood.  Urine  containing  blood  is  usually  red  in  color  or  reddish- 
brown  and  opaque,  but  it  may  be  chocolate-brown  if  the  blood  is 
present  in  large  quantity  and  has  been  acted  upon  by  the  urine.  Such 
urine  necessarily  contains  albumin. 

Blood  occurs  in  the  urine  from(l)  diseases  of  the  kidney  and  urinary 
passages,  among  which  are  Bright' s  disease,  acute  congestion  of  the 
kidney,  renal  calculus,  cancer,  tubercle;  from  ureteritis,  cystitis,  and 
urethritis,  and  from  injuries;  (2)  from  general  diseases,  such  as  the 
eruptive  and  intermittent  fevers,  scurvy,  purpura,  peliosis  rheumatica, 
leucocythseniia,  cholera;  (3)  from  adjacent  organs,  as  in  menstruation 
and  hemorrhage  from  the  uterus  ;  (4)  from  the  toxic  action  of  drugs — 
cantharides,   turpentine,   and   other  violent  irritants  of    the  kidney ; 


DISEASES  OF  THE  KIDNEYS.  687 

(5)  vicariously — occasionally  menstruation  fails  to  occur  and  hematuria 
replaces  it.  The  same  is  true  of  bleeding  from  piles.  Latour  has 
reported  a  case  of  asthma  which  subsided  suddenly  upon  the  appear- 
ance of  hematuria. 

The  chemical  tests  for  blood  are  the  same  as  those  for  its  coloring- 
matter,  and  will  be  referred  to  under  Haemoglobin. 

Haemoglobin.  Haemoglobin  is,  of  course,  present  whenever  blood 
is,  but  sometimes  it  occurs  independently  of  hematuria.  Thus,  it  is 
found  in  grave  infectious  diseases,  as  the  result  of  toxic  action  of 
drugs,  such  as  carbolic  acid,  and  in  an  independent  disease  known  as 
paroxysmal  haemoglobinuria.  A  suitable  test  consists  in  adding  one 
or  two  drops  of  freshly  prepared  tincture  of  guaiac  to  about  one  drachm 
of  urine,  then  shaking  the  mixture  and  adding  several  drops  of  a  solu- 
tion of  hydrogen  peroxide.  If  blood-coloring  matter  be  present,  a 
beautiful  blue  coloration  will  be  produced. 

The  same  test  answers  for  methaemoglobin  and  haematin. 

Paroxysmal  Hcemoglobinuria.  The  urine  contains  blood,  or  only 
the  coloring-matter  of  the  blood  is  present.  Hsemoglobinuria  is  more 
frequent  in  adult  males;  it  may  be  excited  by  a  cold  bath,  or  exposure 
to  cold,  or  by  exertion.  It  is  sometimes  associated  with  Raynaud's 
disease.  The  attacks  come  on  suddenly,  often  preceded  by  chills. 
Sometimes  fever  accompanies  the  disease.  Vomiting  and  diarrhoea 
occur  with  hsemoglobinuria.  Pain  in  the  loins  is  sometimes  complained 
of.  The  paroxysm  may  last  a  day  or  two,  or  two  or  three  paroxysms 
may  occur  in  the  course  of  twenty-four  hours. 

Albumose.  Albumose  has  been  found  in  the  urine  in  osteomalacia 
and  diseases  of  the  medulla  of  bone,  in  dermatitis,  intestinal  ulcer, 
measles,  scarlatina,  and  mental  diseases.  Urine  containing  it  does  not 
respond,  at  first,  to  the  heat  and  nitric-acid  test,  but  on  cooling  a  pre- 
cipitate forms  which  responds  to  the  biuret  test.  (In  this  test  the  urine 
is  first  treated  with  about  one-half  its  volume  of  sodium  hydroxide 
solution,  and  then  a  1  per  cent,  solution  of  cupric  sulphate  is  added 
drop  by  drop.  If  albumose  is  present,  the  resulting  cupric  hydroxide 
is  dissolved,  and  the  fluid  becomes  of  a  violet-red  color.)  The  proba- 
bility of  the  presence  of  albumose  is  strengthened  if  a  turbidity  occurs 
with  the  acetic  acid  and  potassium  ferrocyauide  test  (acetic  acid,  specific 
gravity  1064,  to  which  a  few  drops  of  a  10  per  cent,  solution  of  potas- 
sium ferrocyauide  have  been  added),  and  also  with  the  biuret  test, 
applied  directly  to  the  urine  itself.    Albumin  also  responds  to  this  test. 

Detection  and  Estimation  of  Sugar  (Glucose).  Next  to  albu- 
min, sugar  is  the  most  important  abnormal  constituent  of  the  urine. 
It  is  not  present  in  normal  urines  in  quantities  that  can  be  detected  by 
ordinary  clinical  methods.  The  best  tests  for  its  detection  are  Fehling's 
test  and  the  fermentation  test. 

Fehl'mg's  Test.  Fehling's  solution  is  prepared  by  dissolving  34.652 
grammes  of  pure  crystallized  cupric  sulphate  in  about  200  c.c.  of 
water.  About  173  grammes  of  sodic  potassium  tartrate  (Roehelle 
salt)  are  dissolved  in  about  480  c.c.  of  sodium  hydroxide  solution  of 
1.14  specific  gravity.  The  cupric  sulphate  solution  is  added  slowly 
to  the  sodic  potassium  tartrate  solution,  stirring  constantly  until  all 


688  SPECIAL  DIAGNOSIS. 

of  the  cupric  sulphate  solution  has  been  added.  The  bluish-white 
precipitate  of  cupric  hydroxide  which  first  forms  will,  on  stirring  the 
liquid,  be  completely  dissolved.  The  blue  liquid  is  then  diluted  with 
water  to  exactly  1000  c.c.  One  c.c.  of  this  solution  will  be  reduced 
by  0.005  of  a  gramme  of  glucose.  Fehling' s  solution  is  prone  to 
decomposition,  and  as  much  as  possible  to  avoid  the  occurrence  of 
decomposition  it  is  best  to  keep  the  cupric  sulphate  and  sodic  potas- 
sium-tartrate  solutions  in  separate  bottles  closed  with  rubber  stoppers. 
To  accomplish  this  the  34.652  grammes  of  cupric  sulphate  are  dis- 
solved in  water  and  diluted  to  500  c.c,  and  the  sodic  potassium 
tartrate  is  dissolved  in  water  and  diluted  to  500  c.c,  and  the  two 
solutions  preserved  in  separate  bottles  closed  with  rubber  stoppers. 
The  solution,  prepared  in  this  mauner,  is  made  ready  for  use  by 
mixing  one  volume. of  the  cupric  sulphate  solution  with  an  equal 
volume  of  the  sodic  potassium  tartrate  solution.  The  resulting  liquid 
will  be  Fehling' s  solution,  and  1  c.c  of  it  will  be  equal  to  0.005 
of  a  gramme  of  glucose. 

Certain   precautions  are  necessary  in  the  application  of  this  test. 

1.  Any  albumin  present  must  be  removed  by  boiling  and  filtration. 

2.  The  Fehling  solution,  diluted  with  4  to  5  volumes  of  water,  must  be 
boiled  first  and  the  urine  added  to  it;  the  uriue  must  not  be  boiled 
first  and  the  Fehling  solution  added  to  it.  Boiling  the  reagent  first 
is  a  test  of  its  stability:  if  a  precipitate  occurs,  the  solution  is  unfit 
for  use.  As  Wormley  correctly  says,  a  precipitate  is  more  likely  to 
occur  when  the  Fehliner  solution  has  been  diluted  with  four  or  five 
times  its  volume  of  water  than   on  boiling  the  undiluted  solution. 

3.  Prolonged  boiling  is  to  be  avoided.  The  solution  is  to  be  heated 
to  the  boiling-point  and  the  urine  then  added;  if  no  precipitate  indi- 
cating sugar  occurs  until  urine  is  added  almost  equal  in  volume  to 
that  of  the  reagent,  the  mixture  should  be  again  heated  to  the  boiling- 
point  and  then  set  aside.  4.  When  the  earthy  phosphates  are  abundant 
it  is  well  to  get  rid  of  them  by  adding  a  small  quantity  of  sodium 
hydroxide  and  filtering  before  applying  the  sugar  test.  5.  Changes  in 
color  may  occur  from  the  presence  of  urea,  uric  acid,  and  extractives. 
These  changes  can  be  obviated,  when  necessary,  by  the  method  pro- 
posed by  Seegen,  who  recommends  repeated  filtering  through  animal 
charcoal  until  the  urine  is  rendered  colorless.  Fehling' s  test  is  then 
applied  to  the  filtered  urine. 

The  method  of  applying  Fehling' s  test  is  as  follows:  Fehling' s 
solution  is  poured  to  the  depth  of  about  one-quarter  of  an  inch  into  a 
test-tube,  and  diluted  with  four  or  five  times  its  volume  of  water, 
and  heated  until  it  begins  to  boil;  then  one  or  two  drops  of  the  sus- 
pected urine  are  added.  If  it  be  ordinary  diabetic  urine,  the  mixture 
after  an  interval  of  a  few  seconds  will  suddenly  turn  of  an  intense 
opaque  yellow  or  reddish-brown  color,- and  in  a  short  time  an  abun- 
dant yellow  or  reddish-brown  precipitate  falls  to  the  bottom.  If,  how- 
ever, the  quantity  of  sugar  present  be  small,  the  suspected  urine  is 
added  more  freely,  but  not  beyond  a  volume  equal  to  that  of  the  diluted 
Fehling' s  solution  employed.  In  this  latter  case  it  is  necessary  to 
raise  the  mixture  once  more  to  the  boiling-point.      It  is  then  allowed 


PLATE    IV. 


Crystals  of  Phenyl-glucosazone. 

(Oc.  4,  Obj.  D.i    Drawn  by  J.  D.  Z.  Chase. 


DISEASES  OF  THE  KIDNEYS.  689 

to  cool  slowly.  If  no  cuprous  oxide  has  been  thrown  down  when  the 
liquid  has  become  cold,  then  the  urine  may  be  pronounced  sugar-free. 

Sir  William  Roberts  has  recently  pointed  out  the  value  of  repeated 
filtration  through  animal  charcoal  of  urine  which  reacts  doubtfully  to 
the  test  for  sugar;  by  this  filtration  the  urates,  uric  acid,  and  other 
normal  constituents  of  the  urine,  which  have  more  or  less  power  of 
reducing  Fehling's  solution,  are  removed,  while  the  sugar  passes 
through  and  is  found  in  undiminished  quantity  in  the  filtrate. 

The  test  is  made  as  follows  :  A  test-tube  is  charged  with  Fehling's 
solution  to  the  depth  of  about  one-quarter  of  an  inch,  diluted  with  four 
or  five  times  its  volume  of  water,  and  brought  to  the  boiling-point;  the 
urine,  filtered  through  characoal,  is  added  to  the  depth  of  about  two 
inches,  and  the  two  fluids  mixed.  The  flame  of  a  lamp  is  then  applied 
to  the  upper  half  of  the  column  of  liquid,  and  this  is  boiled  for  a  couple 
of  seconds.  If  sugar  is  present,  the  upper  half  loses  its  blue  color  and 
assumes  a  yellowish  tinge,  and  the  earthy  phosphates  which  are  thrown 
down  in  light  flakes  by  the  alkali  of  the  test  are  tinted  more  or  less 
of  a  gold  color  by  the  precipitation  on  them  of  the  cuprous  oxide. 

The  Fermentation  Test.  This  is  based  upon  the  fact  that  sugar  by 
fermentation  with  yeast  breaks  up  into  alcohol  and  carbon  dioxide. 
It  is  a  reliable  but  not  a  very  delicate  test  for  sugar. 

A  piece  of  yeast-cake  the  size  of  a  pea  is  added  to  a  test-tube  full 
of  urine.  The  open  end  of  the  tube  is  inverted  under  water  in  a 
saucer  or  beaker.  If  sugar  is  present  in  amounts  larger  than  two  and 
a  half  grains  to  the  ounce,  bubbles  of  carbon  dioxide  collect  at  the 
upper  part  of  the  tube  after  standing  twelve  hours  in  a  temperature  of 
about  90°  F. 

The  Phenyl-hydrazin  Ted.  Von  Jaksch  believes  this  test  to  be  a 
very  accurate  one.  About  two  grains  of  phenyl-hydrazin  hydro- 
chloride and  about  three  grains  of  sodium  acetate  are  put  into  a  test- 
tube  half  full  of  water.  The  contents  of  the  tube  are  heated  and  the 
tube  filled  with  the  suspected  urine.  The  tube  is  kept  for  fifteen  or 
twenty  minutes  in  boiling  water,  and  then  put  in  a  vessel  of  cold 
water.  When  a  large  amount  of  sugar  is  present  a  deposit  of  yellow, 
needle-like  crystals  is  visible  to  the  naked  eye;  but  when  only  a 
small  amount  is  present  the  sediment  must  be  examined  under  the 
microscope.  The  crystals  appear  singly,  or  in  sheaves  and  fine  radii. 
Yellow  plates  and  brown  balls  do  not  indicate  sugar.     (Plate  IV.) 

Quantitative  estimation  of  sugar  can  be  made  with  Fehling's  solution 
by  using  a  burette  and  measured  quantities  of  urine  and  reagent. 
Wormley  recommends  a  method  which  answers  very  well  for  office-use: 
One  cubic  centimetre  of  Fehling's  solution  is  diluted  in  a  large  test- 
tube  with  four  cubic  centimetres  of  distilled  water,  and  boiled.  One- 
tenth  of  a  cubic  centimetre  of  the  suspected  urine  is  then  added  from 
a  graduated  pipette.  Heat  is  then  applied,  the  precipitate  watched, 
and  then  another  one-tenth  cubic  centimetre  added,  and  heat  again 
applied.  The  addition  of  one-tenth  of  a  cubic  centimetre,  followed 
by  heat,  is  continued,  until  it  is  found,  after  proper  subsidence,  that  all 
the  color  is  removed  from  the  diluted  Fehling's  solution.  If  in 
doing  this  one  cubic  centimetre  of  urine  has  been  added,  it  will  have 

44 


690  SPECIAL  DIAGNOSIS. 

contained  just  0.5  per  cent,  of  sugar.  If  more  than  one  cubic  centi- 
metre, it  will  have  contained  less  than  0.5  per  cent.  If  exactly  two 
cubic  centimetres  are  used,  it  will  have  contained  exactly  0.25  per 
cent.  If  one-tenth  of  a  cubic  centimetre  has  been  used,  the  urine  will 
have  contained  5  per  cent,  of  sugar.  If  the  quantity  of  sugar  in  the 
urine  is  large,  the  urine  should  first  be  diluted  with  a  measured  volume 
of  water,  allowance  being  made  for  this  in  the  estimation. 

When  the  quantity  of  sugar  is  relatively  large  fermentation  is  the 
simplest  and  most  trustworthy  method.  Roberts  has  shown  that  sac- 
charine urine  loses  by  fermentation  one  degree  in  density  for  every 
grain  of  sugar  contained  in  an  ounce  of  urine.  For  example,  if  the 
urine  before  fermentation  had  a  specific  gravity  of  1040,  and  after 
fermentation  a  specific  gravity  of  1010,  then  the  urine  contained  30 
grains  of  sugar  to  the  ounce.  In  the  application  of  this  method  about 
four  ounces  of  diabetic  urine  are  put  in  a  twelve-ounce  bottle,  and  a 
piece  of  Vienna  yeast,  about  the  size  of  a  pea,  is  broken  up  and  then 
added  to  it.  This  bottle  is  closed  with  a  perforated  cork  to  allow  the 
C02  to  escape,  and  stood  aside  in  a  warm  place  to  ferment.  Beside 
it  is  placed  a  tightly  corked  four-ounce  bottle  filled  with  the  same 
urine,  but  without  any  yeast.  In  about  twenty-four  hours  the  fermen- 
tation will  have  ceased.  The  specific  gravity  of  the  fermented  urine 
is  then  taken  and  also  that  of  the  unchanged  urine.  Every  degree  of 
loss  in  density  represents  one  grain  of  sugar  per  ounce  of  urine. 

Indicax.  An  excess  of  indican  in  the  urine  is  known  as  indican- 
uria.  The  substance  is  detected  by  several  methods.  Jaffe's  test: 
Equal  volumes  of  hydrochloric  acid  and  urine  are  mixed.  By  means 
of  a  glass  pipette  a  solution  of  sodium  hypochlorite  is  dropped  into 
the  fluid.  An  indigo-blue  color  is  produced  if  indican  be  present. 
The  hypochlorite  must  not  be  added  in  excess.  A  quantitative  determ- 
ination is  made  by  the  colorimetric  process  of  Salkowski.  A  rough 
analysis  is  first  made  to  determine  the  quantity  of  calcium  hypochlorite 
which  causes  the  greatest  amount  of  indigo  to  unite  with  it.  If  the  urine 
contains  much  indican,  a  small  portion,  as  2.5  to  5  c.c,  is  diluted  with 
water  to  10  c.c.  If  there  is  but  little  indican,  10  c.c.  of  the  urine  are 
used  without  dilution.  An  equal  quantity  of  hydrochloric  acid  is 
added.  To  this  the  amount  of  hypochlorite  solution  with  which,  in 
the  first  test,  indigo  combined  in  the  greatest  amount  is  added.  Then 
the  liquid  is  neutralized  with  sodium  hydroxide,  then  enough  sodium 
carbonate  is  added  to  make  it  alkaline.  The  indigo-blue  is  thus  pre- 
cipitated and  collected  on  a  filter.  The  precipitate  is  repeatedly  washed 
-with  water  until  the  alkaline  reaction  disappears  The  filtrate  is  dried 
and  extracted  by  heating  with  chloroform,  until  the  latter  no  longer 
assumes  a  blue  color.  The  chloroform  extract  is  increased  to  a  round 
number  of  c.c.  by  the  addition  of  chloroform,  and  placed  in  a  vessel 
with  parallel  sides.  The  intensity  of  "its  color  is  compared  with  a 
freshly  prepared  chloroform  solution  of  indigo-blue  of  known  strength. 
To  one  or  other  of  these  chloroform  is  added  until  the  tint  of  both 
is  the  same.  The  quantity  of  indigo-blue  derived  from  the  urine  is 
determined,  and  its  percentage  calculated  from  the  intensity  of  color 
and  strength  of  the  solution  of  indigo  of  known  strength.      Five  to 


DISEASES  OF  THE  KIDNEYS.  691 

twenty  milligrammes  of  indigo-blue  are  passed  in  twenty-four  hours 
in  health.  Indican  is  increased  by  animal  diet — an  increase  which, 
under  other  circumstances,  is  pathological.  Its  presence  is  a  sign  of  in- 
testinal putrefaction.  It  may  accompany  a  decomposition  of  albumin 
in  cavities.  It  is  present  in  empyema  and  in  puerperal  peritonitis. 
By  detection  of  its  presence  in  these  diseases  cavities  due  to  pus  may 
be  distinguished  from  those  due  to  other  causes.  Indican  is  in- 
creased in  acute  diarrhoea  and  in  intestinal  tuberculosis.  Von  Jaksch 
states  that  large  quantities  of  indican  in  the  urine  imply  that  abundant 
albuminous  putrefaction  or  putrid  suppuration  is  in  progress  in  the 
system.  It  must  not  be  forgotten  that  indicanuria  will  often  arise  in 
simple  constipation. 

Bile-pigments  and  Bile- acids.  Bile-pigment  or  bilirubin  occurs 
in  the  urine  in  cases  of  hepatogenic  and  hematogenic  jaundice  and  in 
portal  thrombosis. 

Gmelin's  test  and  its  modifications  are  the  ones  usually  employed. 
A  small  quantity  of  nitric  acid,  to  which  some  nitrous  acid  has  been 
added,  is  put  into  a  test-tube  and  then  gently  overlaid  with  urine.  If 
bile-pigment  is  present,  a  series  of  colors  appear  at  the  junction  of  the 
two  fluids — green,  blue,  violet,  and  yellow.  A  green  color  (biliverdin) 
must  be  present  to  prove  the  existence  of  bile-pigment. 

The  same  test  may  be  applied  by  placing  a  few  drops  of  the  acid  upon 
one  side  of  a  plate  and  the  urine  on  the  other,  and  then  allowing  the 
two  to  run  together.  The  play  of  colors  takes  place,  as  before,  at  the 
line  of  junction  of  the  acids  and  urine. 

Rosenbach's  modification  is  an  improvement.  About  200  c.c.  of 
urine  are  allowed  to  flow  through  pure  white  filter-paper,  and  then  a 
drop  of  nitric  acid  is  placed  upon  the  paper  saturated  with  the  urine. 
The  colors  appear  as  before  described. 

A  very  simple  test  consists  in  allowing  a  few  drops  of  the  acid  to 
fall  into  a  test-tube  full  of  urine.  If  bile-pigment  is  present,  a  green 
color  appears  at  the  line  of  junction  of  the  two  fluids.  This  test  may 
fail,  however,  if  only  small  quantities  of  bile-pigment  are  present. 

The  tests  for  bile-acids  are  either  too  elaborate  or  too  unsatisfactory 
for  clinical  use. 

Pus.  Pus  is  found  in  the  urine  whenever  there  is  suppuration  or  a 
catarrhal  condition  of  the  genito-urinary  tract.  Hence  it  occurs  in 
abscess  of  the  kidney,  pyonephrosis,  pyelitis,  tubercle,  cystitis,  gonor- 
rhoea, lencorrhoea,  etc.  It  is  relatively  common  in  women,  from  a 
catarrhal  condition  of  the  vulva  and  vaginal  mucous  membrane,  and 
is,  therefore,  of  less  significance  than  in  men.  Urine  containing  much 
pus  is  slightly  albuminous;  but  frequently  pus-cells  are  found  in  urine 
which  gives  no  reaction  for  albumin. 

The  chemical  test  for  pus  is  its  conversion  into  a  tenacious  (gelat- 
inous), glairy  mass  by  boiling  with  caustic  potash. 

Acetonuria.  An  excess  of  acetone  occurs  in  the  following  dis- 
eases :  1,  in  diabetes;  2,  in  cancer  independent  of  starvation;  3,  in 
starvation;  4,  in  certain  psychoses;  5,  in  auto-intoxications;  6,  in 
derangement  of  digestion;  7,  in  fevers.  In  diabetes  acetone  indi- 
cates an  advanced  stage  of  the  disease.     Lieben's  test  for  acetone  is 


692  SPECIAL  DIAGNOSIS. 

as  follows  :  To  several  c.c.  of  urine  a  few  drops  of  iodo-potassium 
iodide  solution  and  sodium  hydroxide  are  added.  If  acetone  is  in 
excess,  the  precipitation  of  iodoform  takes  place,  which  may  be  recog- 
nized by  its  odor. 

Diaceturia.  Diacetic  acid  is  found  in  the.  urine  in  diabetes,  in 
fevers,  and  in  auto-intoxications.  It  is  common  with  children  in  fever. 
It  is  of  grave  significance  when  in  the  urine  of  adults.  Coma  usually 
follows  its  occurrence  in  the  urine  in  fevers  and  in  diabetes.  Test: 
A  concentrated  solution  of  ferric  chloride  is  cautiously  added  to  the 
urine.  If  a  precipitate  be  formed,  it  should  be  removed  by  filtration 
and  more  ferric  chloride  added  to  the  filtrate.  If  diacetic  acid  be 
present,  the  liquid  will  be  claret-red  in  color. 

Microscopic  Examination  of  the  Urine.  Microscopic  examina- 
tion of  the  urine  is  chiefly  concerned  with  the  sediments,  and  these 
are  conveniently  divided  into  the  organized  and  unorganized. 

The  organized  deposits  in  the  urine  are  blood,  pus,  mucus,  epithelium, 
casts,  spermatozoa,  micro-organisms,  cancerous  and  tuberculous  matter, 
entozoa. 

The  unorganized  deposits  are  uric  acid  and  its  compounds,  oxalate 
and  carbonate  of  lime,  phosphates,  leucin  and  tyrosin,  eystin  and 
cholesterin. 

Normal  urine  forms  a  slight  sediment  consisting  of  epithelium  from 
different  parts  of  the  genito-urinary  tract,  principally  from  the  bladder 
in  males,  and  from  the  vagina  and  bladder  in  females.  There  are  also 
some  crystals  of  the  different  urinary  salts,  sometimes  mucus  and  a  few 
white  blood-cells,  and,  if  the  urine  has  stood  awhile,  especially  if 
alkaline,  more  or  fewer  bacteria.  It  may  accidentally  contain  extra- 
neous matter  -  derived  from  the  vessel  which  contains  it  or  from  the 
air.     (Fig.  119.) 

The  centrifugal  machine  has  now  become  an  important  adjunct  to 
the  rapid  and  accurate  microscopical  examination  of  the  urine.  There 
are  now  numerous  varieties  to  be  secured  at  the  instrument-stores,  some 
of  which  are  devised  solely  for  urinary  examination,  while  others  have 
additional  apparatus  for  examination  of  the  blood  and  sputum.  The 
majority  of  them  are  revolved  by  hand.  Electricity  can  be  readily 
applied  to  any  of  them  and  labor  be  saved  by  such  a  device.  The 
advantages  of  centrifugal  force  over  the  older  gravity  method  employed 
in  microscopical  examination  are  marked.  Some  few  of  them  can  be 
briefly  outlined  : 

1.  Centrifugalization  secures  complete,  rapid,  and  concentrated  sedi- 
mentation.     It  is,  therefore,  best  suited  to  microscopical  diagnosis. 

2.  Casts  or  other  organic  material,  if  present,  can  be  studied  care- 
fully before  they  are  macerated  or  partially  destroyed  by  bacteria  or 
changed  by  the  deposition  of  amorphous  or  crystalline  material.  This 
is  a  most  important  aid  to  correct  diagnosis. 

3.  Crystals,  if  present  at  the  time  of  urination,  can  be  discovered 
and  differentiated  from  those  that  normally  crystallize  out  after  some 
hours. 

4.  Certain  bodies,  hyaline  casts,  for  instance,  because  of  their  rather 


DISEASES  OF  THE  KIDNEYS. 


693 


light  specific  gravity,  do  not  settle  on  the  simple  standing  of  the  urine, 
and  thus  escape  detection.  These  with  all  other  substances  are  thrown 
down  with  the  centrifugal  machine. 

5  Bacteria  are  discovered  with  greater  ease,  especially  the  tubercle- 
bacillus. 

The  method  commonly  used  for  the  examination  of  the  urinary  sedi- 
ment is  as  follows:  The  urine  for  examination  (the  chemical  analysis 
having  previously  been  made)  is  decanted  until  there  remains  but  a 
small   amount   in  the   bottle,   which   amount  contains    any  sediment 


Extraneous  matters  found  in  urine  :  a,  cottou-flbres ;  b,  flax-fibres ;  c,  hairs ;  d,  air-bubbles  ; 
e,  oil-globules ;  /,  wheat-starch  ;  g,  potato-starch  ;  h,  rice-starch  granules  ;  i,  i,  i,  vegetable  tissue  ; 
/.-,  muscular  tissue;  I,  feathers. 

already  formed,  and  heavier  organic  materials.  This  is  then  poured 
into  one  of  the  tubes  of  the  centrifugal  machine  to  within  one-half 
inch  of  the  top;  if  but  one  specimen  of  urine  is  to  be  examined,  till 
both  tubes  with  the  same  urine.  If  there  is  not  sufficient  urine  to 
do  this,  fill  the  remaining  tube  or  tubes  with  water.  It  is  well  to 
mark  the  external  metal  shields  of  the  tubes  with  a  figure,  say  1  and 


694 


SPECIAL  DIAGNOSIS. 


2,   or  a  and   b,    so  that  the  urines,   if  different  specimens,  may  not 
become  confused. 

The  tubes  are  then  rapidly  revolved  for  three  minutes,  then  removed 
from  the  machine  and  a  few  drops  of  the  sediment  withdrawn  with  a 
pipette  and  placed  upon  the  slide  for  examination  under  the  micro- 
scope. It  is  necessary  to  remember  that  care  must  be  exercised  in 
removing  this  sediment  from  the  tube.  The  straight  glass  pipette 
without  a  pointed  end  seems  to  give  the  best  results  in  securing  the 
sediment.  The  finger  is  placed  upon  one  end,  the  pipette  inserted  to 
the  bottom  of  the  tube  and  the  finger  is  then  elevated  just  enough  to 
secure  a  few  drops  of  the  sediment  that  has  been  cast  down  by 
centrifugalization.  If  the  urine  contains  but  the  normal  mucous 
cloud,  a  very  small  whitish  sediment  or  cloud  is  found  at  the  bottom 
of  the  tube.  If  oxalate  of  lime  is  present,  a  small  filmy  whitish 
sediment  is  seen.  The  sediment  of  amorphous  urates  is  pinkish,  fawn, 
or  salmon  color.      Uric  acid   appears   as   a    "brick-dust"  sediment. 


Fig.  i:o. 


I 
3*      -   ^. 


" '  Si- A 

x^r  '   ~      '  H  +  y 
1  ' 


V 


^ 


Cellular  elements  from  the  urine.  1,  squamous  epithelium;  2,  red  blood-corpuscles ;  3,  poly- 
nuclear  leucocytes ;  4,  transitional  cells  ;  5,  epithelium  from  the  kidneys  ;  6,  epithelium  from  the 
bladder  ;  7,  micrococcus  aurese ;  8,  yeast-fungi. 

Pus  produces  a  heavy  yellowish  sediment  ;  phosphates  a  heavy  white 
sediment,  which  is  sometimes  yellowish-white  from  admixture  with 
leucocytes.  Blood  in  small  quantities  produces  a  rather  character- 
istic brownish  deposit.  Large  amounts  of  blood  appear  as  reddish 
coagulse  at  the  bottom  of  the  tube. 

AYith  some  of  the  centrifugal  machines  the  various  urinary  salts 
and  the  amount  of  albumin  present  can  readily  be  estimated.  Such 
instruments  are  provided  with  graduated  tubes  in  which  the  urine  and 
the  necessary  reagents  are  put  and  the  resulting  precipitate  rapidly 
cast  down. 

In  this  manner  Purdy  estimates  the  chlorides,  sulphates,  and  phos- 
phates, and  also  the  amount  of  albumin  most  satisfactorily.      It  is 


DISEASES  OF  THE  KIDNEYS.  695 

questionable,   however,  whether  the   estimation  of   the   salts   is   ac- 
curate. 

Organized  Sediments.  Blood.  If  the  blood  comes  from  the 
kidney,  it  is  usually  intimately  mixed  with  the  urine,  which  remains 
of  a  red  or  reddish -brown  color,  and  contains  possibly  tube-casts  and 
renal  epithelium.  The  blood-cells  appear  singly,  have  frequently  lost 
their  haemoglobin,  and  hence  look  like  pale-yellow  disks.    (Fig.  120.) 

Sometimes  blood  coagulates  in  the  ureters,  and  long,  cylindrical  plugs 
are  passed,  causing  symptoms  resembling  those  of  renal  colic.  When 
blood  comes  from  the  bladder  or  neck  of  the  bladder  (fissure)  there 
are  symptoms  of  frequent  micturition,  of  acute  pain  and  tenesmus,  and 
the  blood  is  not  intimately  mixed  with  the  urine.  When  from  the  neck 
of  the  bladder  it  often  occurs  in  a  few  drops  at  the  end  of  micturi- 
tion, accompanied  with  great  pain  and  a  sense  of  faintness.  Intermit- 
tent h&einaturia,  according  to  Von  Jaksch,  points  directly  to  calculus 
or  tumor  of  the  bladder. 

Blood-cells,  when  unaltered,  are  unmistakable  on  account  of  their 
well-known  biconcave  appearance.  When  they  have  lost  their  color- 
ing-matter they  appear  as  circular,  very  pale  disks,  with  extremely 
faint  outline  and  feeble  refractive  power.  Absence  of  a  nucleus  serves 
to  distinguish  them  from  yeast-spores  (Fig.  120),  and  the  latter,  more- 
over, are  often  oval  in  shape.  They  are  less  likely  to  be  confounded 
with  the  ovoid  and  circular  shapes  of  oxalate  of  lime  crystals,  because 
the  latter  are  not  common,  and  can  be  seen  usually  in  their  more  com- 
mon forms  as  octahedra  and  dumb-bells  in  the  same  urine. 

Pus.  The  sources  of  pus  in  the  urine  have  been  referred  to  already. 
The  pus-corpuscle  is  an  opaque,  spherical,  granular  cell,  usually  some- 
what larger  than  are  blood-cells.  In  dilute  urine,  or  urine  to  which 
water  has  been  added,  it  swells  sometimes  to  twice  its  original  size. 
At  the  same  time  it  becomes  less  granular,  and  two,  three,  or  four 
nuclei  may  appear.  In  concentrated  urines  the  pus-cell  is  small.  The 
addition  of  acetic  acid  also  causes  it  to  swell,  and  brings  out  the  nuclei 
more  distinctly  and  rapidly.  Sometimes  the  pus-cells  are  discrete, 
sometimes  in  dense  clumps,  and  sometimes  nothing  but  a  dense  mass  of 
pus-cells  appears  in  the  field  of  the  microscope. 

It  cannot  be  decided  from  microscopic  examination  whether  a  cell  is 
a  pus-corpuscle,  a  mucus-corpuscle,  a  white  blood-cell,  or  an  inflam- 
matory leucocyte.  It  must  be  a  matter  of  inference  from  the  general 
characters  of  the  urine.  If  red  blood-Cells  are  also  present,  the  prob- 
ability of  finding  white  blood-cells  is  increased,  but  pus-cells  are  not 
necessarily  excluded.  So,  too,  if  much  mucus  be  present  in  the  urine, 
the  doubtful  cell  may  be  a  mucus-corpuscle.  Some  clue  to  the  source 
of  the  pus  can  be  obtained  from  the  urine  itself.  Urine  containing  pus 
from  the  kidney  is  usually  acid,  whereas  in  cystitis  it  is  alkaline  and 
almost  always  contains  phosphates,  mucus,  and  abundant  bacteria. 
Again,  pus  from  the  kidney,  or  kidney  pelvis,  is  apt  to  vary  greatly 
in  amounts,  or  be  discharged  intermittently;  and  the  urine,  when 
filtered  free  from  pus-cells,  is  usually  still  albuminous.  Renal  epithel- 
ium and  casts  may  also  be  found. 


696  SPECIAL  DIAGNOSIS. 

Casts.  Casts  are  the  most  important  of  the  urinary  deposits.  They 
vary  greatly  in  number  and  size.  Sometimes  in  acute  nephritis  they 
form  a  considerable  part  of  the  sediment,  but  usually  they  have  to  be 
sought  for  carefully  and  patiently.  A  few  words  as  to  the  method  of 
examining  for  them  may  not  be  superfluous. 

Sedimentation  by  the  centrifugal  machine  is  now  much  in  vogue. 
If  the  centrifugal  machine  cannot  be  employed,  proceed  as  follows  : 

Six  or  eight  ounces  of  the  urine  to  be  examined  should  be  allowed 
to  settle  in  a  bottle  as  soon  after  being  passed  as  possible.  The  bottle 
should  be  tightly  corked,  because  urine  exposed  to  the  air  decomposes 
very  quickly  ;  it  should  be  sent  to  the  person  who  is  to  examine  it  as 
soon  after  being  passed  as  possible,  in  order  that  an  examination  may 
be  made  before  fermentative  changes  spoil  it  for  trustworthy  analysis. 
After  standing  twelve,  or  preferably  twenty -four  hours,  nearly  all  the 
solid  matter  will  have  collected  at  the  bottom  of  the  bottle.  The 
supernatant  clear  fluid  can  now  be  poured  off,  and  the  lower  portion 
of  the  urine  and  the  sediment  poured  into  a  conical  subsiding -glass. 
If  the  urine  is  febr'Jp,  there  may  be  by  this  time  a  large  deposit  of 
amorphous  urates,  which  will  obscure  the  search  for  casts;  thev  may  be 
dissolved  by  gentle  heating  without  destroying  the  casts,  and  the  clear 
urine  again  allowed  to  settle  for  a  few  hours.  So,  too,  if  phosphates 
are  abundant,  they  should  be  gotten  rid  of  by  gentle  heating  and 
acidulation  with  two  or  three  drops  of  dilute  acetic  acid. 

After  the  urine  in  the  conical  subsiding-glass,  which  will  not  now 
amount  to  more  than  an  ounce  or  two,  has  stood  for  a  few  hours,  any 
casts  that  may  be  present  will  have  fallen  to  the  bottom.  If  the  urine 
is  very  concentrated  (1030  or  more),  epithelium,  blood,  aud  casts  will 
be  suspended  longer;  hence  it  rnayjbe  well  to  dilute  the  urine  before 
allowing  it  to  settle. 

A  glass  tube  with  an  internal  diameter  of  about  one-eighth  of  an 
inch,  and  with  one  end  drawn  out  fine,  is  the  most  convenient  thing  for 
collecting  the  sediment.  The  ordinary  glass  pipette  with  a  rubber  suc- 
tion-bulb at  one  end,  commonly  known  as  a  "  medicine-dropper," 
sometimes  answers  admirably.  If  the  common  glass  tube  is  used,  the 
forefinger  of  the  right  hand  should  be  placed  over  the  open  upper  end, 
and  the  fine  lower  end  passed  down  to  the  bottom  of  the  glass.  The 
finger  is  then  removed  sufficiently  to  permit  a  few  drops  to  be  sucked 
in.  The  same  thing  is  attained  if  the  finger  is  entirely  removed  as 
soon  as  the  point  on  the  tube  reaches  the  bottom  of  the  conical  glass; 
but  in  that  case  more  than  the  lowest  layers  of  the  sediment  or  urine 
are  sucked  up,  and  hence  all  but  a  few  drops  should  be  allowed  to  flow 
out  when  the  tube  is  removed  from  the  urine.  In  this  way  the  drops 
preserved  for  microscopical  examination  will  contain  the  sediment  from 
the  very  bottom  of  the  glass.  In  this  sediment,  in  pale  urines  free  from 
much  urates,  phosphates,  and  pus,  the  casts  will  be  found,  if  any  are 
present  in  the  urine.  It  is  most  important  to  examine  the  bottom 
layers  of  the  sediment  when  the  latter  is  scanty,  or  when  phosphates 
or  urates  have  begun  to  precipitate  after  the  urine  has  been  standing 
some  time.  If  the  urine  is  already  cloudy  with  phosphates,  urates,  or 
pus,  when  it  is  put  aside  to  settle,  any  casts  that  may  be  present  will 


DISEASES  OF  THE  KIBXEYS. 


697 


be  carried  down  with  the  heavier  sediment  and  will  be  found  intimately 
mixed  with  it,  or  even  on  top  of  the  other  sediment. 

The  few  drops  preserved  for  microscopic  examination  are  now  depos- 
ited on  several  slides,  without  a  cover-glass,  and  examined  carefully 
for  casts  under  a  power  of  50  to  60  diameters.  Casts  may  be  numer- 
ous, so  that  nearly  every  field  contains  one  dozen  or  more,  or  they  may 


Fig.  121. 


Epithelial  and  hyaline  casts. 


be  very  few,  not  more  than  one  or  two  being  found  on  a  slide.  The 
best  routine  method  for  microscopical  examination  is  as  follows :  place 
a  few  drops  of  the  urinary  sediment  upon  the  slide;  spread  the  drops 


Fig.  122. 


Hyaline  casts  and  eylindroids  in  hypostatic  congestion  of  kidney.    Low  power. 

in  a  thin  layer;  use  no  cover-glass;  examine  with  the  low  power — a 
diameter  of  50 — with  a  small  amount  of  light;  the  whole  slide  cau 
be  carefully  searched  in  three  minutes,  and  casts  discovered  can  be 
minutely  studied  with  the  higher  power.     When   but  few  casts  are 


698 


SPECIAL  DIAGNOSIS. 


present,  several  slides  can  be  rapidly  examined  with  the  low  power, 
and  an  accurate  estimation  of  the  number  made. 

All  the  pipettes  used  in  examining  urine  must  be  kept  clean.  They 
should  be  allowed  to  stand  in  water  which  is  frequently  changed,  and 
carefully  rinsed  in  running  water  before  being  used. 


Flfi.  12ft. 


Hyaline  easts  from  a  case  of  acute  nephritis.    1,  plain  hyaline  cast ;  2,  granular  deposit  on 
hyaline  cast ;  3,  cellular  deposit  ("blood  and  epithelium). 

Tube-casts  usually  indicate  acute  or  chronic  nephritis;  but  they  are 
sometimes  found  in  cases  of  renal  calculi;  in  icterus,  usually  without 
albuminuria;  in  diabetes,  and  sometimes  in  secondary  congestion  of 
the  kidney.. 

Fig.  124. 


Several  varieties  of  casts  are  found.      1.   Hyaline  casts,  as  their  name 
implies,  are  clear,  translucent  bodies,  which  refract  light  so  slightly 


PLATE    V. 
FIG  i. 


-  — 
1 


Q  I 


«^ 


i.  Hyaiine  Casts  with  Granular  Matter  and  Epithelial  Cells  deposited  upon  them. 
2.  Amyloid  (waxy)  Cast. 


(Oc.  4.  ob.  D.)    Drawn  by  J.  D.  Z.  Chase. 


FIG  2. 


Q 


© 


A*/     ®kM$' 


Blood-casts  from  Case  of  Acute  Nephritis. 
(Oc  I.  ob.  D.)    Drawn  by  J.  D.  /..  Chase. 


DISEASES  OF  THE  KIDNEYS.  699 

that  they  are  easily  overlooked.  They  have  well-defined  margins,  the 
ends  being  frequently  rounded;  they  are  rarely  very  long,  and  are 
straight,  or  but  slightly  bent.  They  are  rarely  equally  translucent 
throughout;  at  some  pait  more  or  less  granulation  will  generally  be 
found.  They  vary  in  diameter  from  that  of  a  white  blood-cell  to  six 
or  eight  times  as  large.  They  can  be  stained,  and  so  rendered  more 
distinct,  by  allowing  a  drop  of  gentian-violet  solution  to  flow  in  under 
the  edge  of  the  cover-glass.  (Figs.  121  and  123.)  2.  Granular  casts 
are  hyaline  casts  which  appear  granular  either  from  some  deposit  on 
their  surface  or  from  a  granular  change  of  the  cast  itself.  When  the 
granulation  does  not  interfere  with  the  translucency  the  casts  are  de- 
scribed as  "pale"  or  "  slightly"  granular;  and  when  they  become 
very  dark,  so  as  to  resemble  closely  a  blood-cast,  they  are  called 
"dark"  or  "opaque"  granular  casts.  (Plate  V.,  Fig.  1,  1,  and 
Figs.  123, 124.)     3.   Waxy  casts  appear  to  the  eye  to  be  more  solid  in 

Fig.  125. 


Fatty  casts  from  a  case  of  chronic  parenchymatous  nephritis. 

structure  than  the  hyaline  casts;  they  also  appear  more  cylindrical  in 
form,  are  more  or  less  yellow  in. color,  and  are  apt  to  be  larger  than 
hyaline  casts.  (Plate  V.,  Fig.  1,  2.)  4.  Fatty  casts  are  hyaline  or 
faintly  granular  casts  on  which  are  deposited,  in  spots,  minute  oil-drops. 
They  are  sometimes  called  "  oil-casts"  if  the  oil-drops  are  very  abun- 
dant. (Fig.  125.)  5.  Blood-casts  are  either  made  up  of  a  mass  of 
blood-cells  pressed  together  into  a  cylindrical  shape,  or,  more  frequently, 
a  hyaline  cast  is  studded  with  blood-cells.  (Plate  V.,  Fig.  2.)  6. 
Epithelial  casts  sometimes  seem  to  be  composed  entirely  of  epithelial 
cells  closely  packed  together.  Such  casts  are  relatively  rare,  and  very 
beautiful.  Ordinarily,  just  as  in  the  case  of  blood-casts,  an  epithelial 
cast  consists  of  a  hyaline  cast  more  or  less  covered  with  renal  epithelium. 
(Plate  V.,  Fig.  1,  1,  and  Fig.  121.)  7.  Dr.  George  Johnson  has  de- 
scribed casts  composed  of  ^ws-corpuscles.  In  two  cases  in  which  they 
were  found  in  the  urine  the  patients  were  found  at  autopsy  to  have 


700 


SPECIAL  DIAGNOSIS. 


multiple  abscesses  of  the  kidney.  8.  Cylindroids  are  very  common- 
In  general  appearance  they  resemble  hyaline  casts  ;  but  they  are  apt  to 
be  much  longer,  bent,  twisted  or  split,  and  to  have,  on  close  examina- 
tion, a  striated  or  finely  ribbed  appearance.  Moreover,  the  diameter 
of  the  cast  frequently  varies  greatly  at  different  points;  sometimes  it 


Fig.  12<i. 


Cylindroids. 


appears  constricted  in  several  places,  and  in  other  cases  one  end  tapers 
off  into  a  thread.  Often  cylindroids  consist  of  fine,  narrow,  ribbon- 
like threads.     (Figs.  122  and  126.) 

Spermatozoa.     Spermatozoa  are  easily  recognized  by  their  tadpole 
shape  and  by  the  vibratile  motion  of  their  long,  delicate  tails.     They 


Fig.  127. 


Human  semen,  a,  spermatozoa ;  6,  cylindrical  epithelium  ;  c,  bodies  enclosing  lecithin  gran- 
ules ;  d,  squamous  epithelium  from  the  urethra  ;  d',  testicle-cells  ;  e,  amyloid  corpuscles  ;  /,  sper- 
matic crystals  ;  g,  hyaline  globules.    (Von  Jaksch.) 


are  found  in  the  uriue  of  both  sexes  after  sexual  intercourse.     (Figs. 
127  and  128.) 

Many  continent  men  have  ocasionally  nocturnal  emissions,  accom- 
panied by  erections  and  erotic  sensations.     These  cannot  be  looked 


DISEASES  OF  THE  KIDNEYS. 


701 


upon  as  abnormal,  and  they  are  compatible  with  robust  health.  There 
are  other  persons,  neurotic,  anaemic,  and  generally  constipated  in  habit, 
who  have  emissions  at  night  two  or  three  times  a  week,  of  which  they 
are  unconscious  until  they  wake  and  find  themselves  wet.  Semen  may 
also  be  lost  during  micturititon  and  defalcation,  especially  when  much 
straining  is  required.  Such  a  condition  (spermatorrhoea)  is  abnormal. 
It  is  due  to  general  nervous  and  muscular  relaxation,  associated  with 
nervous  dyspepsia  and  anaemia,  and  aggravated  by  sedentary  life,  con- 
stipation, and  the  reading  of  salacious  literature  or  the  cultivation  of 
erotic  thoughts.  Iii  young  men  it  sometimes  follows  habits  of  mastur- 
bation, which  have  been  broken  up  but  have  left  behind  a  hyperaes- 
thetic  condition  of  the  prostatic  portion  of  the  urethra,  with  or  without 
dilatation  of  the  orifices  of  the  ejaculatory  ducts;  or  a  stricture  of  gon- 
orrhoea! origin  may  be  its  cause.  Students  and  overworked  and  over- 
strained business  and  professional  men  are  the  ones  most  frequently 
affected. 


Fig.  128. 


Spermatozoa  from  urine. 


However  caused,  the  condition  is  apt  to  beget  a  most  distressing 
state  of  despondency,  in  which  the  patient  imagines  all  possible  ills 
and  is  liable  to  drift  into  an  hysterical,  melancholic,  even  suicidal 
frame  of  mind,  and  so  falls  a  victim  to  quacks. 

Epithelium.  Epithelium  from  the  kidney,  bladder,  and  genito- 
urinary passages  occurs  in  the  urine.  Epithelial  deposits  in  male  urine 
are  very  scanty,  unless  there  is  some  disease  of  the  kidney  or  bladder, 
or  a  catarrhal  condition  of  the  prostatic  urethra,  such  as  is  left  from 
an  old  gonorrhoea.  On  the  other  hand,  considerable  epithelium  may 
be  normally  present  in  the  urine  of  women,  being  derived  principally 
from  the  vagina  and  bladder. 

Vaginal  epithelium  consists  of  large,  flat  pavement-cells,  and  is 
readily  distinguished. 

The  type  of  epithelium  of  the  kidney,  kidney  pelvis,  ureter,  and 
bladder  is  the  same,  and  it  is  not  possible  to  distinguish  with  certainty 


702  SPECIAL  DIAGNOSIS. 

the  cells  which  come  from  each.  If  the  cells  are  scanty,  Von  Jaksch 
thinks  they  come  from  the  ureter.  He  has  found  them  in  moderate 
quantities  and  superimposed  upon  one  another. 

Renal  cells  closely  resemble  the  oval  polygonal  cells  from  the  deeper 
layers  of  the  bladder,  but  they  have  a  relatively  larger  nucleus.  (See 
Fig.  120.) 

Fat.  Oil  is  found  in  the  urine  in  fatty  degeneration  of  the  kidney 
and  its  epithelium,  and  occasionally  in  the  urine  of  those  who  are  taking 
cod-liver  oil,  and  in  calculous  disease  of  the  pancreas.  Tyson  suggests 
that  it  may  come  from  cystic  cheesy  degeneration  of  the  kidney. 

Lipurta.  Fat  is  found  in  chronic  nephritis,  in  phosporus-poison- 
ing,  and  in  diabetes  mellitus,  as  well  as  in  chyluria.  The  urine  is 
turbid,  but  clear  when  agitated  with  ether.  The  fat  may  be  separated 
by  a  sedimentator,  and  can  be  recognized  by  its  refracting  properties. 

Chyluria.  This  is  a  more  or  less  milky  condition  of  the  urine, 
due  to  the  presence  of  fat,  which  probably  gains  entrance  to  some  part 
of  the  urinary  tract  by  rupture  of  the  lymphatic  vessels.  A  case  has 
been  reported  by  Saundby  in  which  a  young,  unmarried  girl,  being 
pregnant,  compressed  her  abdomen  so  much  in  order  to  conceal  her 
condition  that  oedema  of  the  legs,  thigh,  vulva,  and  lower  parts  of  the 
abdomen  resulted.  After  her  confinement  the  urine  became  milky, 
and  remained  so  for  many  days.  It  contained  fatty  matters,  choles- 
terin,  but  no  albumin  or  sugar. 

Fat  and  albumin  appear  at  the  same  time  in  some  diseases.  They 
recur  at  long  intervals.  Red  and  white  blood-corpuscles  are  also 
found  in  small  amounts.  The  urine  coagulates  on  standing,  or  gelat- 
inizes. It  is  due  to  the  invasion  of  the  urinary  tract  by  the  filaria 
sanguinis  hominis,  the  embryo  of  which  is  found  in  the  urine. 

Parasitic  chyluria  is  due  to  the  filaria  sanguinis  hominis,  whose 
embryos  obstruct  the  lymphatics. 

Entozoa.  The  most  common  is  the  echinococcus  or  hydatid.  When 
this  infects  the  kidney  or  urinary  vessels  booklets  and  even  cysts  have 
been  passed  in  the  urine.  The  disease  is,  of  course,  extremely  rare 
in  this  country. 

The  filaria  sanguinis  hominis,  which  causes  parasitic  chyluria,  is 
occasionally  found  in  the  urine.     (See  Filaria.) 

The  Bilharzia  hoematobia  sometimes  lodges  in  the  urinary  tract  and 
causes  hematuria.     It  is  peculiar  to  Egypt. 

Intestinal  worms  may  creep  into  the  bladder  through  fistulous  or 
other  openings,  and  be  discharged  through  the  urethra. 

Micro-organisms.  Normal  urine  contains  no  micro-organisms  at 
the  time  it  is  voided.  As  the  result  of  exposure  to  the  air,  however, 
they  may  develop  in  great  abundance.  The  non-pathogenic  organisms 
found  are  classed  as  mould-fungi  (hyphomycetes),  yeast-fungi  (blasto- 
mycetes),  and  fission-fungi  (schizomycetes). 

Mould-fungi,  according  to  Von  Jaksch,  are  rarely  found  in  foul 
normal  urine.  Yeast-fungi  are  also  rare  in  normal  urine.  Fission- 
fungi  are  found  in  urine  undergoing  ammoniacal  decomposition. 

Sarcinse,  usually  smaller  than  those  of  the  stomach,  are  occasion- 
ally met  with — especially,  according  to  Roberts,  when  there  is  some 


PLATE    VI. 

Fig.  i. 


^2 


j^ 


£$      B 

rr 


whT*^k  m 


Uric  acid. 

A.  Common  forms,     li.  Amorphous  urates. 
(Ob.  D.  and  A.,  Oc.  4.)    Drawn  by  J.  D.  Z.  Chase. 


Fig.  2. 


£y 


&j      ^ 


3 


\V 


6>\& 


Combination  of  Uric  Acid  and  Calcium  Oxalate. 

(Oc.  I,  01>.  D.i    Drawn  by  J.  D.  Z.  chase. 


DISEASES  OF  THE  KIDNEYS.  703 

disorder   of   the   urinary   organs,   renal    pains,    painful    micturition, 
cystitis,  etc. 

Under  the  name  bacteriuria  Roberts  and  others  have  described  cases 
in  which  the  urine  contained  bacteria  at  the  time  of  being  voided.  He 
makes  four  groups  :  (1)  Cases  in  which  the  presence  of  bacteria  is 
associated  with  incipient  putrefactive  changes  in  the  urine;  (2)  cases 
associated  with  ammoniacal  fermentation  of  the  urine  ;  (3)  cases  in 
which  common  forms  of  bacteria  are  present  without  decomposition  of 
the  urine;  and  (4)  cases  in  which  micrococcus-chains  are  voided  in 
the  urine. 

Fig.  129. 

Vibriones  in  urine.    (Roberts.) 

The  pathogenic  organisms  which  are  more  or  less  closely  associated 
with  infectious  diseases,  septic  processes,  and  tuberculosis,  are  found 
at  times  in  the  urine,  and  can  be  demonstrated  by  the  proper  staining- 
methods. 

Dock  has  given  an  admirable  account  of  the  occurrence  of  the  tri- 
chomonas in  the  genito-urinary  passages.  This  parasite  belongs  to 
the  flagellate  infusoria.  The  prominent  symptoms  caused  in  Dock's 
case  were  painful,  difficult,  and  frequent  urination,  followed  by  hse- 
maturia.  The  urine  contained  pus,  epithelium  of  all  kinds,  and  a 
number  of  bodies  slightly  larger  than  pus-corpuscles  of  a  peculiar 
amyloid  appearance — the  trichomonades. 

Morbid  Growths.  The  urine  very  rarely  contains  the  elements 
of  morbid  growths.  Yon  Jaksch  says  he  never  has  found  them  in 
any  way  reliable  in  the  case  of  tumors  of  the  kidney.  The  detection 
of  cancer-cells  or  pigmented  cells,  such  as  occur  in  melanotic  cancers, 
may  confirm  the  diagnosis  if  the  clinical  symptoms  point  to  cancer. 
Tumor-elements  are  most  likely  to  be  found  in  ulcerating  tumor  of 
the  bladder. 

Unorganized  Sediments.  Uric  Acid.  Uric  acid  is  present  in 
small  quantities  (eight  to  ten  grains  a  day)  in  normal  urine.  It  is 
increased  in  febrile  and  wasting  diseases,  such  as  phthisis;  in  diseases 
of  the  liver  and  spleen  (leukaemia),  and  in  malarial  fever,  diabetes, 
scurvy,  rhachitis,  and  following  an  attack  of  gout.  Excessive  use  of 
milk  is  said  to  increase  it.  Its  excretion  is  also  increased  by  certain 
drugs — colchicum,  corrosive  sublimate,  salicylic  acid,  and  euonymin. 

It  is  diminished,  in  anaemia,  chlorosis,  and  during  a  paroxysm  of 
gout ;  in  chronic  nephritis  ;  by  certain  drugs — large  doses  of  quinine 
(Ranke),  caffein,  sodium  chloride  and  sodium  carbonate,  lithia,  and 
iodide  of  potash.      (Plate  VI.,  Figs.  1  and  2.) 

According  to  Roberts,  a  deposit  of  uric  acid  occurring  some  twelve 
to  twenty-four  hours  after  the  urine  has  been  passed  has  no  patholog- 


704 


SPECIAL  DIAGNOSIS. 


ical  significance.  If  the  deposit  occurs  within  three  or  four  hours  after 
the  urine  has  been  passed,  it  is  certainly  not  natural:  it  is  frequently 
observed  in  convalescence  from  febrile  complaints,  especially  articular 
rheumatism  ;  also  in  the  middle  periods  of  chronic  Bright' s  disease,  in 
chorea,  iu  certain  types  of  diabetes,  and  in  enlargement  of  the  spleen. 
If,  however,  the  uric  acid  is  precipitated  before  the  urine  cools,  or 
immediately  afterward,  it  is  probable  that  the  same  precipitation  may 
occur'within  some  part  of  the  urinary  passages,  and  so  form  a  calculus. 


Fig.  130. 


Fig.  131. 


Sodium  urate. 
a  a.  From  a  gouty  coucretion  ;  b  b.  Arti- 
ficially prepared  by  adding  liq.  sodse  to  the 
amorphous  urate  deposit.    (Roberts.) 


Ammonium  urate  spontaneously 
deposited. 

o.  Spheres  and  globular  masses  ;  b. 
Dumb-bells,  crosses,  rosettes.  (Rob- 
erts.) 


Urates.  Amorphous  urates  appear  under  the  microscope  as  opaque 
granular  particles,  which  dissolve  upon  heating,  and  respond  to  the 
murexid  test.  The  deposit  is  more  or  less  dense,  and  is  sometimes 
arranged  so  as  to  resemble  granular  casts. 


Fir.  132. 


Ammonium  urate. 


Sodium  urate  appears  as  spherules  or  globules  from  which  project 
short  spines,  either  straight  or  curved.      It  occurs  most  frequently  in 


DISEASES  OF  THE  KIDNEYS. 


705 


concentrated  acid  urines,  such  as  are  passed  by  children  with  acute 
febrile  diseases.     (Fig.  130.) 

Ammonium  urate  resembles  sodium  urate,  except  that  it  has  no 
spines.  It  is  frequently  associated  with  phosphatic  deposits,  and  is 
precipitated  from  alkaliDe  urines.  •  Sometimes  it  appears  in  the  shape 
of  dumb-bells.     (Figs.  131  aud  132.) 

Phosphates.  Phosphate^  appear  in  the  urine  as  ammonio-magnesium 
phosphate  and  as  the  crystalline  and  amorphous  phosphate  of  lime. 
They  are  precipitated  in  alkaline  or  faintly  acid  urines,  which  produce 
a  cloud  upon  being  heated;  the  cloud  is  distinguished  from  albumin, 
as  already  pointed  out,  by  the  fact  that  it  disappears  when  the  urine  is 
acidulated  with  acetic  or  nitric  acid.  Ammonio-magnesium  phosphate 
is  easily  recognized  by  its  rhombic  prisms — u  coffin-lid  "  shape.  Other 
shapes  are  produced  by  modification  of  the  primary  one,  chiefly  by 
bevelling  of  the  edges  and  hollowing  out  of  the  sides.  These  crystals 
are  usually  large,  and  are  frequently  found  together  with  amorphous 
phosphates,  bladder  epithelium,  and  pus,  in  cases  of  cystitis. 

Fig.  133. 


Triple  phosphates. 

Amorphous  phosphate  of  lime  consists  of  fine  granular  particles, 
much  resembling  amorphous  urates,  but  distinguished  from  them  ba- 
llot disappearing  upon  the  application  of  heat,  but  instantly  dissolving 
when  the  urine  is  acidulated. 

Crystalline  phosphate  of  lime  is  a  rare  deposit.  It  is  found  as  rods 
or  needles,  and  occasionally  grouped  together  in  the  form  of  stars, 
sheaves,  or  bundles. 

According  to  Roberts,  this  deposit,  in  quantity,  is  an  accompaniment 
of  some  grave  disorder.  He  has  fouud  the  stellar  phosphates  in  cancer 
of  the  pylorus,  once  in  phthisis,  and  more  than  once  in  patients  ex- 
hausted by  obstinate  rheumatism.  It  may,  however,  occur  in  health, 
when  the  urine  is  rich  in  lime  aud  its  acidity  greatly  reduced. 

In  one  or  two  cases  of  renal  colic  the  writer  has  observed  numerous 
shining  particles,  which,  upon  microscopical  examination,  have  been 

45 


706 


SPECIAL  DIAGNOSIS. 


shown  to  be  an  opalescent  film,  covered  with  small,  sharp  phosphatic 
(probably  calcium)  crystals.    (Fig.  135.) 


Fig.  134. 


Calcium  sulphate  crystals. 


Oxalate  of  Lime.     Oxalate  of  lime  occurs  in  the  form  of  small  octa- 
hedral crystals,  or,  more  rarely,  as  dumb-bells,  and  in  the  form  of 


Pig.  135. 


Opalescent  film  in  a  case  of  renal  colic. 

ovals  or  disks.  It  is  precipitated  almost  always  from  acid  urines. 
(Plate  VI.,  Fig.  2,  and  Fig.  136.) 

Oxaluria.  According  to  Beneke,  oxaluria  has  its  proximate 
cause  in  an  impeded  metamorphosis,  an  insufficient  activity  of  that 
stage  which  changes  oxalic  acid  into  carbonic  acid. 

When  oxalates  are  constantly  found  in  the  urine  a  condition  of 


DISEASES  OF  THE  KIDNEYS. 


707 


profound  hypochondriasis  is  found  to  exist,  but  it  has  no  necessary- 
relation  to  the  oxaluria.  An  iucrease  of  oxalates  in  the  urine  is  found 
in  diabetes,  especially  when  there  is  diminution  in  the  amount  of 
sugar.  It  is  in  excess  in  certain  forms  of  indigestion.  Its  constant 
passage  may  be  attended  by  pains  in  the  back  and  loins.  Flatulent 
and  nervous  dyspepsia  usually  accompany  the  increase,  and  neuras- 
thenia also  may  be  present. 

Fig.  136. 


4a    % 


S>! 


H 


&  S3     g 


(jrfa 


0. 


<N_,    c 


Calcium  oxalate. 

Cystin.  Cystin  occurs  in  the  form  of  hexagonal  prisms,  either  as 
irregular  masses  or  superimposed  one  upon  another,  so  as  to  form 
truncated  pyramids.  It  is  a  very  rare  sediment,  but  appears  to  be 
most  common  in  children  and  young  male  adults.  Several  members  of 
the  same  family  have  been  known  to  pass  it.  Its  chief  clinical  sig- 
nificance arises  from  the  fact  that  rarely  it  is  the  basis  of  calculi. 


Fig.  137. 


Crystals  of  lcucin  (different  forms).  (Crystals  ot.creatinin  chloride  of  zinc  resemble  the  leucin 
crystals  depicted  at  a.)  The  crystals  figured  toward  the  right  consist  of  comparatively  impure 
leuci  n .    (From  Charles  :  Chemistry. ) 

Leucin  and   Tyrosin.     Leucin  and  ty rosin  are  generally  described 
together,  though  the  former  is  not  spontaneously  deposited  from  urine. 


708 


SPECIAL  DIAGNOSIS. 


It  appears  in  the  form  of  spheres  which  refract  light  strongly  and 
have  a  radiating  arrangement.     (Fig.  137.) 

Tyrosin  has  been  found  as  a  sediment,  of  a  light  greenish -yellow 
color,  in  typhoid  fever  and  acute  yellow  atrophy  of  the  liver.  It 
appears  in  the  form  of  tolerably  long,  needle-like  crystals,  or  as  bun- 


Fig.  138. 


Tyrosin  crystals. 


dies  and  sheaves.  Frerichs  attaches  great  importance  to  leucin  and 
tyrosin  in  the  diagnosis  of  acute  yellow  atrophy  of  the  liver.  (Fig. 
138.) 


Fig.  139. 


Crystals  of  cholesteriu. 


Cholesterin.  This  occurs  at  times  in  fatty  degeneratiou  of  the  kid- 
neys, jauudice,  chyluria,  diabetes,  and,  according  to  Pohl,  in  the  urine 
of  epileptics  treated  with  bromide  of  potash.      (Fig.  139.) 


DISEASES  OF  THE  KIDNEYS.  709 

Mel.anu.ria.  Melanin  is  held  in  solution  or  suspended  in  small 
granules.  The  urine  is  dark  in  color,  and  blackens  intensely  when 
sulphuric  acid  or  tincture  of  chloride  of  iron  is  added  to  it.  A  con- 
centrated solution  of  perchloride  of  iron  serves  to  detect  the  presence 
of  the  substance.  A  few  drops  added  to  the  urine  turn  it  gray.  If 
a  few  drops  more  are  added,  the  phosphates  are  precipitated  along 
with  the  coloring-matter.  Both  are  dissolved  by  an  excess  of  the  iron 
solution.     Melanin  is  usually  found  in  cases  of  melanotic  carcinoma. 

Objective  Symptoms  due    to    Impairment  of  the  Function 
of  the  Kidney.     Uraemia. 

Under  symptoms  due  to  impairment  of  the  functions  of  the  kidney 
belong  the  various  manifestations  of  uraemia.  Diseased  kidneys  do 
not  eliminate  the  products  of  tissue-waste,  which  are  poisonous  ma- 
terials. The  toxic  matter  is  retained  within  the  blood,  and  produces 
a  toxaemia,  which  may  be  acute  or  chronic.  In  acute  urcemia  the 
manifestations  develop  suddenly  and  continue  but  a  short  period  of 
time,  with  alarmingly  active  symptoms  until  death  or  recovery.  In 
chronic  uraemia  the  onset  is  gradual.  The  manifestations  may  be  limited 
to  one  or  two  conditions,  as  headache  or  morning  nausea,  or  they  may 
include  the  more  pronounced  symptoms  of  uraemia. 

Nervous  Symptoms.  1.  Headache.  The  pain  is  situated  in  the 
occipital  region,  and  may  extend  down  the  neck.  It  is  severe  and  of 
a  bursting  character.  It  may  be  associated  with  giddiness.  In  both 
acute  and  chronic  nephritis  it  is  often  the  first  manifestation.  It  may 
be  associated  with  eye  symptoms.  It  may  be  present  on  waking,  and 
continue  only  through  the  morning  hours.  In  acute  uraemia  it  persists 
throughout  the  attack.  Numbness  and  tingling  of  the  fingers  are  often 
complained  of  at  the  same  time. 

2.  Delirium.  The  delirium  may  be  mild.  This  is  usually  the  case 
in  the  typhoid  state  or  if  a  subnormal  temperature  prevails.  It  is  some- 
times attended  by  delusions.  There  is  often  subsultus,  and  picking  at 
the  bedclothing.  The  delirium  may  amount  to  true  mania,  and  the 
patient  may  exhibit  other  maniacal  symptoms.  On  the  other  hand, 
the  patient  may  be  noisy,  restless,  and  sleepless.  Melancholia  and 
delusional  insanity  may  develop  after  the  violent  nervous  symptoms  of 
uraemia  pass  off. 

3.  Convulsions.  A  convulsion  may  be  the  first  indication  of  disease 
of  the  kidneys,  or  it  may  succeed  a  few  days  of  persistent  headache, 
or  follow  an  attack  of  uraemic  vomiting.  The  convulsion  resembles 
epilepsy,  and  hence  is  known  as  an  epileptiform  convulsion.  If  the 
spasms  recur  in  rapid  succession,  the  interval  is  occupied  by  delirium 
or  coma.  If  they  are  infrequent,  the  patient's  mind  may  be  clear  in  the 
intervals.  Sometimes  a  focal  or  Jacksonian  epilepsy  occurs  instead  of 
the  true  epileptiform  convulsion.  The  temperature  is  usually  elevated. 
In  worn-out  subjects,  or  those  who  have  had  exhaustive  diarrhoea  or  are 
debilitated  from  other  causes,  the  temperature  may  be  subnormal.  A 
temporary  blindness  often  follows  the  convulsion  (urcemic  amaurosis). 
Uraemic  deafness  may. occur. 


710  SPECIAL  DIAGNOSIS. 

4.  Coma.  After  the  convulsion  the  mind  may  be  restored,  or  the 
patient  may  lapse  into  stupor  followed  by  complete  coma.  Coma  may 
develop  without  convulsions,  or  immediately  succeed  a  general  convul- 
sion. Headache  or  eye-symptoms  may  precede  the  coma.  In  some 
instances  the  patient  lapses  into  a  typhoid  state  in  which  the  tongue  is 
heavily  furred  and  the  breath  very  offensive.  Unless  the  coma  is  very 
profound  there  is  usually  some  twitching  of  the  muscles  of  the  hands 
and  face. 

5.  Local  Palsies.  Dercum  was  among  the  first  to  call  attention  to 
the  occurrence  of  ureemic  monoplegia  or  hemiplegia.  The  cases  re- 
semble central  cerebral  disease.  The  nature  of  the  palsy  is  inferred 
from  the  results  of  the  examination  of  the  urine  and  the  condition  of 
the  heart  and  arteries.  Palsy  develops  suddenly,  or  may  occur  after  a 
convulsion. 

6.  Cramps  in  the  muscles  of  the  calves,  particularly  at  night,  are 
of  common  occurrence,  and  should  always  lead  to  an  examination  of 
the  urine. 

7.  Pruritus,  local  or  general,  is  another  nervous  symptom  which 
may  be  of  ursemic  origin. 

8.  Pain  in  the  upper  abdomen,  particularly  iu  the  median  line,  is 
a  frequent  precursor  of  more  severe  uraemic  symptoms.  It  is  of  urse- 
mic origin  itself.  It  may  be  seated  in  either  of  the  upper  quadrants, 
and  thence  extend  to  the  lower  portion  of  the  abdomen. 

Ursemic  Dyspncea.  Modifications  of  the  breathing  often  accom- 
pany symptoms  of  uraemia.  The  dyspnoea  may  be  constant.  It  may 
occur  in  paroxysms,  or  both  types  may  alternate.  A  common  type  in 
the  uraemia  of  chronic  nephritis  is  the  Cheyne-Stokes  breathing.  Par- 
oxysmal dyspnoea  usually  occurs  at  night,  and  resembles  asthma  in 
every  respect.  Cheyne-Stokes  breathing  continues,  even  through  the 
period  of  coma,  although  not  necessarily  associated  with  it  (see  page 
297). 

Gastrointestinal,  Symptoms  of  Uremia.  Several  forms  are 
seen.  1.  Loss  of  appetite  is  common.  It  is  attended  with  absolute 
distaste  for  food  after  a  small  portion  is  taken.  2.  Nausea,  which 
may  be  continuous,  or  more  frequently  limited  to  the  early  morning. 
3.  Vomiting  may  be  paroxysmal,  occurring  chiefly  in  the  early  morn- 
ing, or  it  may  be  sudden  in  onset,  uncontrollable,  and  continue  until 
nervous  symptoms  of  uraemia  develop.  Urea  is  found  in  the  vomit. 
The  matter  ejected  is  profuse,  of  a  low  specific  gravity,  and  at  first  acid 
in  reaction.  If  chronic,  it  may  become  alkaline.  The  odor  is  often 
sufficient  to  cause  its  recognition.  4.  Constipation  is  generally  the  rule 
in  the  course  of  chronic  Bright' s  disease.  5.  Diarrhoea.  One  of  the 
manifestations  of  uraemia  is  the  occurrence  of  sudden,  profuse  serous 
purging.  This  may  be  so  extreme  as  to  cause  collapse,  or  may  usher 
in  coma  and  convulsions.  6.  Hiccough,  although  a  muscular  affection, 
is  usually  associated  with  gastric  disturbances. 

Acetonemia.  Acetonemia  is  a  toxaemia  which  develops  in  the  ter- 
minal stages  of  diabetes.  It  is  due  to  an  accumulation  of  acetone  in 
the  blood.  It  is  also  called  diabetic  coma.  It  develops  acutely.  A 
sudden  onset  is  attended  by  sharp  pain  in  the  stomach  with  nausea, 


DISEASES  OF  THE  KIDNEYS.  711 

and  frequently  vomiting.  At  the  same  time  there  is  severe  dyspnoea. 
The  breathing  is  irregular  and  of  a  panting  character,  with  inspiratory 
and  expiratory  dyspnoea.  There  may  or  may  not  be  cyanosis.  The 
patient  is  obliged  to  sit  up  in  bed  on  account  of  the  air-hunger.  Rest- 
lessness begins  at  once.  Delirium  develops  within  the  first  hour.  In 
a  few  hours  coma  sets  iu.  The  temperature  is  subnormal;  the  pulse 
is  irregular,  and  soon  becomes  weak  and  thready.  The  odor  of  acetone 
is  detected  on  the  breath. 

Cardio-vascular  Symptoms.  The  symptoms  are  the  effects  of 
the  retention  of  morbid  products.  First,  the  heart  and  bloodvessels. 
The  poison  which  is  not  excreted  circulates  throughout  the  system.  One 
of  its  effects  is  irritation  of  the  vasomotor  nerves  of  the  bloodvessels. 
Excitation  of  these  nerves  causes  peripheral  contraction  of  the  smaller 
vessels.  At  once  the  flow  of  blood  is  obstructed,  so  that,  on  account  of 
the  contraction,  hypertrophy  of  the  heart  rapidly  ensues.  The  first 
prominent  symptom,  therefore,  is  due  to  changes  in  the  heart-muscle. 

Hypertrophy  of  the  Heart.  The  most  pronounced  change  is 
hypertrophy.  The  persistent  spasm  of  the  peripheral  vessels  causes 
increased  arterial  tension.  The  blood-pressure  is  raised  and  causes 
increased  accentuation  of  the  aortic  second  sound.  High  tension  in 
the  artery  is  recognized  by  the  peculiar  character  of  the  pulse  and  by 
means  of  the  sphygmograph. 

Dilatation  of  the  Heart.  Unfortunately,  hypertrophy  of  the 
heart  cannot  always  be  kept  up.  If  it  fails,  we  then  have  a  second 
condition  of  the  heart  which  is  frequently  found  in  renal  inflamma- 
tions; it  is  dilatation.  The  state  of  the  coronary  arteries  predisposes 
to  this  condition  of  the  heart-muscle.  The  previously  mentioned  arte- 
rial tension  favors  the  development  of  chronic  endarteritis  with  gen- 
eral atheroma.  The  coronary  arteries  take  part  in  this  process.  The 
endarteritis  hinders  cardiac  nutrition,  dilatation  of  the  heart-muscle 
follows,  and  later  comes  the  development  of  two  other  conditions, 
atrophy  and  myocarditis. 

Here  may  be  mentioned  other  relations  of  the  heart  and  kidneys: 
a.  We  have  renal  disease  following  forms  of  cardiac  disease.  In  dila- 
tation of  the  heart  passive  congestion  of  the  particular  organ  takes 
place.  The  kidney  very  quickly  becomes  the  seat  of  such  congestion. 
In  the  course  of  simple  dilatation,  or  of  valvular  heart  disease,  the 
secondary  dilatation,  passive  congestion,  and  chronic  inflammation 
develop  slowly.  Embolism  may  also  occur,  b.  Renal  disease  and 
cardiac  disease  may  develop  at  the  same  time  from  a  common  cause, 
as  alcoholism,  gout,  or  endarteritis. 

In  addition  to  high  arterial  tension  and  accentuation  of  the  aortic 
second  sound,  the  objective  symptoms  of  atheroma  of  the  aorta  and 
arteries  are  present  with  the  chronic  inflammations  of  the  kidney. 
These  vascular  changes  need  not  be  again  rehearsed.  (See  Endarter- 
itis.) 

It  is  important,  however,  to  bear  in  mind  that  they  frequently  occur 
together,  and  also  that  in  all  instances  of  arterial  disease  the  condition 
of  the  urine  must  be -inquired  into.     It  need  not  be  said  that  symp- 


712  SPECIAL  DIAGNOSIS. 

toms  due  to  rupture  of  the  bloodvessels,  particularly  in  the  brain,  or 
to  aneurism,  necessarily  may  be  present  in  the  course  of  renal  inflam- 
mation. 

Hemorrhages.  The  arteries  are  very  liable  to  rupture,  causing 
epistaxis,  retinal  hemorrhage,  hemorrhages  from  the  bowels  and  lungs, 
and  hemorrhages  underneath  the  skin.  Frequent  hemorrhages  in 
large  amounts  from  any  portions  of  the  body  should  call  attention  to 
the  condition  of  the  urine. 

Ophthalmoscopic  Changes.  The  eye-ground  should  always  be 
examined;  indeed,  the  patient  himself  by  his  complaints  often  directs 
attention  only  to  the  eye,  the  examination  of  which  discloses  the  pres- 
ence of  an  albuminuric  retinitis.  The  changes  may  occur  in  the 
acute  or  chronic  forms  of  nephritis,  although  they  are  more  common 
in  the  latter.  1.  A  diffuse  slight  opacity  and  swelling  of  the  retina, 
due  to  oedema.  2.  White  spots  or  patches  of  various  sizes,  for  the 
most  part  the  result  of  degenerative  processes.  3.  Hemorrhages.  4. 
Inflammation  of  the  intraocular  end  of  the  optic  nerve.  5.  Atrophy 
of  the  retina  and  nerve  may  sometimes  result  from  and  succeed  the  in- 
flammatory changes.  These  changes  may  affect  one  eye  only  (Gowers). 
It  must  not  be  forgotten  that  temporary  blindness  may  occur  inde- 
pendently of  retinitis. 

Dropsy.  Dropsy  may  occur  in  all  forms  of  nephritis.  It  is  most 
common  in  acute  varieties,  but  it  is  also  present  in  chronic  diffuse 
nephritis  with  exudation.  Renal  dropsy  usually  begins  in  the  face.  It 
may  develop  suddenly  in  acute  forms.  In  the  marked  forms,  oedema  of 
the  eyelids  may  continue  for  a  long  time.  All  varieties  may  be  found, 
from  local  oedema  to  extreme  anasarca.  The  serous  cavities  are  also 
filled.  The  oedema  is  usually  associated  with  a  diminished  amount  of 
urine.  Its  improvement  is  attended  by  increased  diuresis.  Dropsy, 
in  chronic  disease,  is  usually  due  to  dilatation  of  the  heart  (see  page  96). 

The  Cutaneous  Symptoms,  and  Appearance  of  the  Face. 
In  inflammatory  affections  of  the  kidney,  the  appearance  of  the  skin 
and  expression  of  the  face  are  often  characteristic,  and  point  at  once  to 
an  examination  of  the  urine.  The  face  is  pallid,  and  of  an  ivory 
whiteness.  In  the  chronic  forms  the  pallor  gives  way  to  an  ashen- 
gray  or  sallow  complexion.  In  chronic  nephritis  the  skin  becomes  dry 
and  harsh,  and  rarely  is  covered  with  a  powdery  substance,  giving  it 
the  appearance  of  frost  on  the  skin.  The  powdery  substance  is  due  to 
urea. 

Petechia?.  In  the  later  stages  of  chronic  inflammatory  affections 
hemorrhages  under  the  skin  and  in  the  mucous  membrane  are  seen. 

Anaemia.  Anaemia  is  a  frequent  symptom  in  all  forms  of  nephritis; 
it  is  usually  marked.  It  is  associated  with  the  peculiar  pallor  just 
described,  and  attended  by  all  the  other  usual  symptoms. 

General  Symptoms.  The  cause  of -renal  disease,  as  far  as  symp- 
toms pointing  to  the  kidneys  are  concerned,  is  often  latent.  Instead 
of  renal  symptoms,  a  generally  depraved  state  of  the  system  may  be 
seen,  with  emaciation  and  weakness.  Lassitude  without  cause  demands 
an  examination  of  the  urine. 

Respiratory  Symptoms.     In  addition  to  ursemic  respiratory  phe- 


DISEASES  OF  THE  KIDNEYS.  713 

nomena,  the  occurrence  of  pulmonary  complications  may  be  the  first 
indication  that  the  condition  of  the  urine  should  be  inquired  into. 
Bronchitis,  pneumonia,  and  pleurisy  are  common  complications. 

Gasteo-intestinal  Symptoms.  Ursemic  symptoms  have  been  re- 
ferred to.  Fermentative  dyspepsia,  gastralgia,  chronic  gastritis,  enter- 
itis, ulcerative  colitis,  and  constipation  are  of  common  occurrence. 

Congestion  of  the  Kidney. 

Congestions  of  the  kidney  are  acute  and  chronic,  and  depend  upon 
changes  in  the  circulation,  whereby  blood  accumulates  in  the  kidney. 

Acute  Congestion  of  the  kidney  is  caused  by  the  action  of  irritant 
poisons  ;  it  follows  surgical  operations,  particularly  if  prolonged,  and 
may  follow  extirpation  of  one  kidney.  Diseased  kidneys  are  apt  to 
become  the  seat  of  active  congestion. 

Symptoms.  The  urine  is  diminished  in  amount,  or  may  be  sup- 
pressed entirely.  Only  a  small  amount  is  passed  at  frequent  intervals, 
or  it  can  be  secured  by  the  catheter  alone.  Albumin  is  present  in  con- 
siderable amount,  and  blood  and  epithelial  casts  are  numerous.  Death 
may  take  place  with  symptoms  of  uraemia. 

Chronic  Congestion  of  the  Kidney.  It  is  also  called  passive  conges- 
tion. This  form  of  congestion  is  usually  a  part  of  general  venous 
stasis  due  to  disease  of  the  heart  or  lungs,  as  valvular  disease  of  the 
heart  with  secondary  dilatation  or  pulmonary  emphysema.  It  is  quite 
common. 

Symptoms.  The  urine  is  diminished  in  amount;  dark  in  color;  of 
high  specific  gravity,  ranging  from  1020  to  1030.  Uric  acid  and 
urates  are  increased.  Urea  to  the  amount  of  from  10  to  12  grains  to 
the  ounce  is  passed  in  twenty-four  hours.  At  first  there  is  no  further 
change,  but,  subsequently,  albumin  appears  in  small  amounts  in  an 
intermittent  manner.  Later  it  is  constant  and  inci  eased  Jn  amount. 
Hyaline  casts  are  found  in  the  urine,  and  a  few  red  blood-cells. 

The  condition  is  recognized  by  its  association  with  congestion  in 
other  organs;  by  the  diminution  in  the  amount  of  urine,  its  high 
specific  gravity,  and  excess  of  uric  acid  and  urates.  This  form  of 
congestion  is  serious,  because  it  leads  to  chronic  nephritis.  The  latter 
is  recognized  by  the  usual  changes  in  the  urine. 

Inflammations  of  the  Kidney. 

The  inflammations  of  the  kidney  are  divided  in  accordance  with  the 
activity  of  the  process,  and  the  degree  of  exudation  or  cell-prolifera- 
tion that  attends  the  inflammation.  We,  therefore,  have  the  follow- 
ing varieties  : 

Acute  exudative  nephritis  (acute  Bright' s  elisease). 

Acute  productive  or  diffuse  nephritis  (acute  Bright' s  disease). 

Chronic  productive  or  diffuse  nephritis  with  exudation  (chronic 
tubular  nephritis). 

Chronic  productive  or  diffuse  nephritis  without  exudation  (chronic 
interstitial  nephritis). 


714  SPECIAL  DIAGNOSIS. 

Suppurative  nephritis. 

Tubercular  nephritis. 

Acute  Exudative  Nephritis  or  Glomerulonephritis.  In 
this  form  of  nephritis  there  are  congestion,  exudation  of  plasma,  trans- 
udation of  red  and  white  blood-cells,  and  changes  in  the  epithelium. 

Causes.  It  may  occur  without  definite  cause,  save  exposure  to  cold, 
and  at  times  even  without  such  history.  It  occurs  in  most  of  the 
infectious  diseases.  It  is  of  common  occurrence  after  scarlet  fever, 
and  in  the  course  of  pregnancy  and  in  septicaemia.  It  occurs  in  diph- 
theria, erysipelas,  and  pneumonia  frequently.  It  is  the  expression  of 
a  peculiar  type  of  typhoid  fever.  It  may  complicate  dysentery  and 
acute  tuberculosis.  It  forms  one  of  the  modes  of  termination  of 
diabetes. 

Symptoms.  The  course  of  the  disease  may  be  mild,  presenting  only 
changes  in  the  urine,  or  there  may  be,  in  addition  to  decided  changes 
in  the  character  of  the  urine,  local  and  general  symptoms. 

In  mild  cases  the  urine  is  diminished  in  amount;  micturition  is  fre- 
quent ;  the  color  of  the  urine  is  increased,  and  the  specific  gravity  is 
usually  high.  A  small  amount  of  albumin  is  found,  and  a  few  epithe- 
lial and  blood-casts,  and  sometimes  blood.  At  the  termination  of  the 
disease  the  casts  are  hyaline. 

In  severe  cases  the  disease  is  ushered  in  by  chill,  attended  and 
followed  by  pain  in  the  loins,  with /ewer,  headache,  and  much  restless- 
ness. 

The  urine  may  be  passed  more  frequently  than  usual,  but  in  small 
amounts;  or  micturition  may  diminish  in  frequency  or  cease  entirely. 
Examination  of  the  urine  reveals  the  characteristic  changes.  The 
quantity  of  the  urine  is  lessened;  the  specific  gravity  is  normal  or 
increased.  There  is  a  large  amount  of  albumin,  and  an  abundance  of 
hvaline,  granular,  epithelial,  and  blood-casts.  Free  white  and  red 
blood-cells,  and  epithelium  from  the  pelvis  and  tubules  are  found. 

The  fever  continues;  the  pain  in  the  loins  is  sometimes  very  severe, 
and  may  be  taken  for  lumbago,  unless  an  examination  of  the  urine  is 
made.  Within  the  first  forty-eight  hours  the  characteristic  symptoms 
that  follow  the  chill  and  that  attend  the  urinary  changes  are  headache, 
sleeplessness,  more  or  less  stupor,  muscular  twitchings,  or  general  con- 
vulsions. Eye-symptoms  may  be  present.  Instead  of  cerebral  symptoms, 
dyspnoea  may  be  marked.  With  both,  nausea  and  vomiting  are  of  com- 
mon occurrence.  The  heart's  action  is  increased  in  force  and  frequency. 
The  left  ventricle  rapidly  becomes  hypertrophied.  The  aortic  second 
sound  is  accentuated.  The  pulse  is  hard  and  exhibits  the  characteristic 
features  of  high  tension.  From  the  onset  of  the  first  symptom,  or 
within  the  first  week,  two  other  striking  phenomena  arise.  They  are, 
first,  the  occurrence  of  dropsy;  second,  the  occurrence  of  ancemia. 

Dropsy  or  oedema  is  one  of  the  most  constant  symptoms.  It  appears 
first  in  the  face,  especially  the  eyelids.  It  may  be  limited  to  this 
region.  It  is  worse  in  the  morning.  From  the  face,  in  bad  cases,  it 
extends  to  the  lower  extremities  and  to  the  scrotum,  and  thence  all 
over  the  body.  Anasarca  is  the  name  applied  to  the  geueral  dropsy; 
the  connective  tissue  is  infiltrated  with   serum.      It  is  recognized  by 


DISEASES  OF  THE  KIDNEYS.  715 

the  pallor  of  the  swollen  surface;  the  pitting  on  pressure;  the  absence 
of  heat  and  of  pain.     (See  page  93.) 

Effusion  may  take  place  into  the  serous  cavities,  either  the  pleura, 
pericardium,  or  peritoneum,  causing  the  symptoms  due  to  effusion. 
In  some  instances  there  is  oedema  of  the  mucous  membranes,  as  the 
conjunctiva,  the  soft  palate,  and  the  glottis. 

Dyspnoea  may  be  a  pronounced  symptom,  due  either  to  uraemia 
(umemic  asthma)  or  oedema  of  the  glottis,  effusions  into  the  pleura,  or 
to  bronchitis.  If  dilatation  of  the  heart  occurs,  dyspnoea  may  arise, 
due  to  that  or  to  the  secondary  oedema  of  the  lungs. 

With  or  without  the  occurrence  of  nausea  or  vomiting  there  is  always 
loss  of  appetite,  aud  usually  constipation. 

The  fever  is  usually  moderate  and  irregular  in  type.  Prostration  is 
common ;  often  there  is  emaciation.  Symptoms  of  urmmia  may  occur 
at  any  time. 

Exudative  nephritis  with  excessive  pus  is  of  sudden  onset,  character- 
ized by  high  fever  and  extreme  prostration.  There  is  rapid  emaciation 
and  the  early  development  of  the  typhoid  state.  This  is  preceded  by 
delirium,  headache,  and  stupor,  with  great  restlessness.  There  is  but 
little,  if  any,  dropsy.  Large  numbers  of  red  and  white  blood-cells 
and  the  usual  casts  are  found  in  the  urine.  There  is  not  so  much 
diminution  in  the  urine  as  is  usually  seen.  The  disease  may  arise 
without  cause,  or  complicate  scarlet  fever  or  diphtheria. 

This  form  is  very  fatal,  and  resembles  acute  meningitis,  from  which 
it  is  diagnosticated  bv  the  change  in  the  urine. 

Acute  Productive  or  Diffuse  Nephritis.  In  this  form 
there  is  an  overgrowth  of  connective  tissue,  and  excessive  growth  of 
the  capsule-cells  in  the  glomeruli,  in  addition  to  the  lesions  of  the  first 
form.  The  whole  kidney  is  not  necessarily  affected,  but  only  portions 
at  a  time.  Symptoms :  The  onset  is  sudden.  The  subjective  symptoms 
previously  described  are  present  in  a  marked  degree.  Nervous  symp- 
toms (uraemia)  are  most  pronounced.  Dropsy  develops  rapidly  and 
to  an  extreme  degree.  There  is  rapid  development  of  anosmia  and 
loss  of  flesh.  The  remaining  symptoms  tally  with  those  of  the  first 
affect  iou. 

The  urine  is  scanty,  bloody,  aud  of  high  specific  gravity.  The 
microscopical  appearances  are  like  those  of  acute  exudative  nephritis. 
If  convalescence  is  established,  the  urine  becomes  more  abundant,  with 
a  corresponding  fall  in  the  specific  gravity.  The  albumin  and  casts 
may  appear  for  a  time,  but  eventually  disappear. 

Diagnosis.  The  diagnosis  of  acute  nephritis  of  either  form  is  based 
upon  the  examination  of  the  urine.  ^Etiological  associations  are  of 
value.     The  more  pronounced  cases  follow  scarlet  fever  and  pregnancy. 

In  the  latter  condition  it  usually  advances  slowly.  There  may  be 
no  symptoms  until  the  occurrence  of  uraemia  or  acute  lung-symptoms. 
In  sonic  instances  the  disease  resembles  typhoid  fever.  In  case-  in 
which  the  onset  is  sudden,  with  early  uraemic  symptoms,  it  must  not 
be  mistaken  for  epilepsy,  delirium,  or  mania. 

Chronic  Productive  or  Diffuse  Nephritis  with  Exuda- 
tion.    In  chronic  inflammations  the  formation  of  new  tissue  always 


716  SPECIAL  DIAGNOSIS. 

takes  place.  They  are  divided,  therefore,  into  exudative  and  non- 
exudative  inflammations.  The  exudation  is  from  the  vessels.  Causes  : 
This  form  usually  follows  acute  productive  nephritis  aud  chronic 
congestions  or  degenerations  of  the  kidney.  It  develops  in  the  course 
of  syphilis,  tuberculosis,  endocarditis,  disease  of  the  bones,  and  pro- 
longed suppuration.  Frequent  exposure  to  cold  and  Avet,  a  residence 
in  damp  dwellings,  and  the  alcoholic  habit  are  causal  conditions.  It 
usually  occurs  in  middle  life,  more  frequently  in  men.  When  it 
occurs  as  a  primary  disease  it  is  usually  found  in  young  adults. 
Symptoms  :  The  disease  develops  slowly.  General  symptoms  may  first 
be  observed.  Dropsy  may  develop  at  first  and  continue  throughout 
the  disease,  or  recur  at  long  intervals.  The  appearance  of  the  patient 
is  striking.  The  skin  is  of  a  peculiar  pallor-  and  is  pasty  in  appear- 
ance. The  sclerotics  are  very  white.  The  anosmia  which  gives  rise 
to  the  pallor  is  very  profound,  and  often  closely  resembles  that  of 
pernicious  anaemia.  The  anaemia  is  due  to  diminution  in  the  haemo- 
globin and  reduction  in  the  number  of  red  blood-cells. 

Headache  and  sleeplessness  are  common  symptoms.  Pronounced  acute 
ursamia  does  not  often  occur.  Chronic  uraemia  may  prove  fatal  by  the 
patients  lapsing  into  a  typhoid  state  in  which  delirum  alternates  with 
stupor. 

The  urine  is  variable  in  quantity  and  character.  It  must  not  be  for- 
gotten that  the  course  of  the  disease  and  the  urinary  symptoms  are 
often  quite  variable  in  chronic  nephritis.  The  urine  may  be  normal 
in  amount,  but  during  the  exacerbations  it  is  scanty  or  suppressed. 
The  specific  gravity  and  the  amount  of  urea  lessen.  In  the  most  rapid 
cases  it  varies  between  1012  and  1020.  In  chronic  cases  it  falls  as  low 
as  1005  and  even  1001.  In  the  later  stages  the  amount  of  the  urine 
and  the  specific  gravity  may  both  be  increased.  Albumin  is  present 
in  large  amounts.  When  the  disease  is  most  active,  and  the  dropsy  at 
its  height,  the  quantity  of  albumin  is  very  large.  In  the  quiescent 
period  of  the  disease  the  amount  is  lessened.  Casts  are  abundant,  both 
epithelial,  fatty,  and  granular;  red  blood-cells  are  often  found. 

Retinitis  albuminuria  is  frequently  developed  in  the  course  of  the 
disease. 

Dyspnoea  is  a  common  symptom.  The  dyspnoea  may  be  due  to 
any  one  of  the  many  causes  previously  described  which  produce  this 
symptom  in  the  course  of  nephritis.  It  is  frequently  limited  to  sudden 
attacks  which  develop  in  the  night  or  early  morning.  There  is  often 
some  bronchial  catarrh. 

Nausea  and  vomiting  are  common  symptoms.     The  appetite  is  lost. 

Hypertrophy  of  the  left  ventricle  takes  place  in  all  cases,  except  in 
those  who  had  been  previously  weakened  by  other  disease.  The  right 
ventricle  is  often  hypertrophied  also.  The  second  aortic  sound  is 
accentuated,  and  the  pulse  is  of  high-  tension.  Symptoms,  such  as 
headache  and  vertigo,  arise  on  account  of  the  profound  anosmia. 

The  disease  is  characterized  in  its  course  by  remissions  and  exacer- 
bations. During  the  exacerbations  any  one  of  the  prominent  symp- 
toms that  occur  in  renal  inflammations  may  be  present.  (Edema  is  the 
one  symptom  which  occurs  most  frequently,  and  is  likely  to  continue 


DISEASES  OF  THE  KIDNEYS.  717 

the  longest.  The  disease  lasts  from  three  months  to  three  years,  and 
may  pass  into  the  second  variety  of  chronic  inflammation. 

Course  of  the  Disease.  Delafield  has  well  outlined  the  course.  The 
constant  symptoms  are  anaemia,  dropsy,  and  albuminuria.  1.  The 
symptoms  may  be  continuous  and  progressive  in  severity,  death  taking- 
place  at  the  end  of  one  or  two  years,  on  account  of  dropsy  or  uraemia. 
2.  The  symptoms  may  continue  for  several  months,  and  the  patient 
finally  improve.  Recurrent  attacks  take  place,  the  symptoms  being 
more  severe  with  each  attack.  In  the  intervals  of  the  attacks  there 
is  a  small  amount  of  albumin  in  the  urine.  3.  The  patient  may  appar- 
ently recover,  but  the  urine  continues  to  be  of  low  specific  gravity, 
and  contains  some  albumin.  A  fatal  attack  of  uraemia,  or  an  apoplexy, 
or  the  onset  of  an  acute  disease  may  cau-e  an  exacerbation  of  the 
renal  symptoms.  4.  The  symptoms  may  persist  in  a  mild  degree 
for  years,  the  patient  at  the  same  time  feeling  comparatively  well. 
5.  Spasmodic  dyspnoea  may  be  the  first  and  only  symptom  for  a  long 
time. 

Chronic  Productive  or  Diffuse  Nephritis  without  Exu- 
dation. This  is  the  form  of  nephritis  which  is  also  called  interstitial 
nephritis,  granular  kidney,  or  cirrhosis  of  the  kidney. 

The  kidneys  are  diminished  in  size,  the  capsules  adherent,  and  the 
surface  roughened.  There  is  an  overgrowth  of  connective  tissue  with 
atrophy  of  the  epithelium  and  of  the  tubules,  and  dilatation  of  some 
of  the  tubes,  forming  cysts. 

Causes.  This  form  of  nephritis  follows  chronic  congestion  of  the 
kidney,  and  is  also  caused  by  alcohol,  lead,  gout,  syphilis,  malaria, 
and  by  chronic  endarteritis.  The  latter  condition,  as  well  as  cirrhosis 
of  the  liver  and  pulmonary  emphysema,  frequently  develop  hand-in- 
hand  with  the  nephritis.  This  form  of  nephritis  is  notably  prevalent 
in  several  generations  of  different  families,  so  that  an  hereditary  history 
is  often  readily  obtained. 

Symptoms.  The  onset  of  the  disease  usually  occurs  late  in  life, 
although  well-defined  cases  may  occur  as  early  as  1  he  twenty-fifth  year. 
The  progress  at  first  is  very  insidious,  and  the  disease  may  have  ad- 
vanced to  an  extreme  stage  without  the  occurrence  of  a  single  symp- 
tom. Death,  indeed,  may  be  due  to  other  causes  ;  or  a  person  in 
apparently  perfect  health  may  suddenly  manifest  symptoms  of  uraemia, 
or  may  develop  apoplexy  or  some  other  usual  accompaniment  of  inter- 
stitial nephritis. 

The  urine  is  increased  in  amount,  clear  in  color,  and  of  low  specific 
gravity.  The  albumin  is  small  in  amount,  or  may  be  absent.  Repeated 
examinations  extending  over  a  considerable  period  of  time  may  dis- 
close its  presence.  Hyaline  casts  are  present  in  small  numbers.  In 
some  cases  it  may  be  necessary  to  examine  a  dozen  or  fifteen  slides 
before  they  are  found.  Sometimes  there  are  a  few  red  blood-cells. 
Rarely  the  urine  is  bloody  at  irregular  periods  in  the  course  of  the 
disease,  or  actual  hematuria  may  take  place.  With  the  exception  of 
the  state  of  the  urine,  the  only  symptom  present  may  be  the  loss  of 
flesh  and  strength.  At  the  same  time  the  skin  becomes  dry  and  harsh. 
(Edema,  however,  is  not  usually  present  unless  there  is  dilatation  of 


718  SPECIAL  DIAGNOSIS. 

the  heart.  Special  symptoms  are  due  to  uraemia,  to  changes  in  the 
heart  and  arteries,  and  to  neuro-retinitis. 

The  Heart.  The  left  ventricle  hypertrophies.  The  aortic  second 
sound  is  accentuated.  The  arterial  pulse  is  of  high  tension.  The 
arteries  become  more  prominent,  and  present  all  the  signs  of  endarter- 
itis. In  the  later  stages,  as  nutrition  fails,  dilatation  of  the  heart 
takes  place  with  regurgitation  at  the  mitral  valve,  and  the  develop- 
ment of  a  train  of  symptoms  due  to  these  changes.  Among  others  we 
find  general  malaise,  palpitation  of  the  heart,  dyspnoea,  oedema,  and 
visceral  congestions. 

Urcemic  /Symptoms.  These  symptoms  may  occur  at  any  time  in  the 
course  of  the  disease.  Headache  is  most  common  and  constant.  It 
may  occur  in  the  early  morning  only,  or  continue  throughout  the  day. 
It  may  be  continuous  and  cause  sleeplessness.  General  neuralgic  pains 
may  be  present  instead  of  severe  headache.  Muscular  twitchings  or 
general  convulsions  may  be  other  pronounced  symptoms,  or,  instead, 
delirium,  mild  or  violent,  stupor,  and  coma  may  come  on.  These 
symptoms  occur  suddenly  or  develop  very  gradually.  In  acute  urae- 
mia with  the  above-mentioned  cerebral  symptoms  there  is  peripheral 
spasm  of  the  arteries,  causing  high  arterial  tension,  and  there  is  eleva- 
tion of  the  temperature.  The  fever  may  rise  to  103°  or  104°,  but 
is  usually  about  102°,  and  is  irregularly  continuous.  After  the  patient 
lapses  into  deep  coma,  if  the  attack  is  fatal,  the  tension  of  the  pulse 
is  lost,  and  it  is  increased  in  frequency  and  diminished  in  strength. 
In  chronic  uraemia  the  cerebral  symptoms  develop  gradually.  The 
temperature  is  likely  to  be  subnormal,  particularly  if  diarrhoea  or 
other  debilitating  influence  is  coincident.  The  pulse  is  rapid  and 
feeble. 

Pulmonary  symptoms  due  to  uraemia  are  c[uite  common.  They  may 
be  the  first  expression  of  uraemia.  This  is  seen  in  all  forms  of  nephritis. 
The  most  marked  symptom  is  dyspnoea,  which  is  spasmodic  and  of 
short  duration.  The  attacks  may  occur  frequently,  and  are  usually 
increased  by  exertion  and  aggravated  by  a  recumbent  posture.  The 
shortness  of  breath  may  occur  in  the  early  morning  hours,  or  may 
continue  throughout  the  day. 

Gastro-intedinal  Symptoms.  Catarrhal  gastritis  almost  always  com- 
plicates nephritis.  In  addition,  gastric  symptoms  due  to  uraemia,  and 
hence  to  deficient  action  of  the  kidney,  ensue.  The  most  common  is 
the  occurrence  of  morning  nausea  or  of  morning  vomiting;  the  occur- 
rence of  spasmodic  vomiting  at  irregular  periods,  or  the  occurrence  of 
violent,  acute  vomiting  which  is  followed  in  two  or  three  days  by  other 
symptoms  of  uraemia.  The  patients  are  usually  constipated.  When 
the  disease  is  complicated  with  cirrhosis  of  the  liver,  intestinal  catarrh 
is  common,  and  intestinal  ulceration  with  consequent  diarrhoea  is  fre- 
quently found.  The  onset  of  uraemia  may  be  characterized  by  violent 
and  profuse  serous  purging,  which  of  itself  may  cause  collapse  and 
death. 

Neuro-retinitis  is  a  frequent  complication  of  nephritis,  and  may 
advance  more  rapidly  than  other  complications,  so  that  dimness  of 
vision,  blindness,    or  other  eye-symptoms   may  cause  the  patient   to 


DISEASES  OF  THE  KIDNEYS.  719 

consult  an  oculist  before  attention  is  called  to  the  condition  of  the 
kidneys.  The  occurrence  of  this  complication  points  at  once  to  the 
necessity  of  an  examination  of  the  urine. 

It  is  common,  in  the  course. of  an  interstitial  nephritis,  to  have  acci- 
dents due  to  the  condition  of  the  arteries  that  accompanies  this  disease. 
On  account  of  the  atheroma,  aided  by  the  hypertrophied  heart,  rupture 
of  the  vessels  frequently  takes  place.  Apoplexy  is,  therefore,  of  com- 
mon occurrence,  and  hemorrhage  into  other  organs  sometimes  occurs. 
There  is  always  a  tendency  to  chronic  inflammations  of  the  mucous 
membranes,  and  to  acute  inflammations  of  serous  membranes  in  the 
course  of  chronic  diffuse  nephritis.  It  is  necessary,  therefore,  when 
local  inflammations  of  this  character  are  present,  to  make  thorough 
and  repeated  examinations  of  the  urine,  especially  in  a  patient  over 
forty  years  of  age,  with  a  history  of  one  of  the  causal  factors  pre- 
viously mentioned. 

Pulmonary  symptoms,  other  than  those  of  uraemia,  may  be  due  to 
an  intercurrent  bronchitis,  pneumonia,  or  pleurisy.  Chronic  bronchitis 
or  oedema  of  the  lungs  may  be  present  on  account  of  dilatation  of  the 
right  heart.  The  chief  pulmonary  symptoms  that  poiut  to  these  con- 
ditions are  dyspnoea  and  cough. 

Course  of  the  Disease.  Several  forms  of  interstitial  nephritis  are 
observed.  In  the  latent  form  the  disease  may  have  advanced  to  an 
extreme  degree  without  any  symptoms  of  renal  disease  during  life, 
death  taking  place  from  an  intercurrent  disease  or  accident.  On  the 
other  hand,  palpitation  of  the  heart  may  be  the  only  symptom  com- 
plained of,  and  the  observer  finds  a  hard  pulse,  general  atheroma,  and 
hypertrophy  of  the  left  ventricle  with  accentuation  of  the  second  sound. 
Apart  from  this  the  patient  may  enjoy  very  good  health.  The  dan- 
ger lies  in  the  occurrence  of  pneumonia  or  inflammation  of  a  serous 
membrane.  Often  the  local  inflammatory  symptoms  are  slight  or 
masked  by  the  symptoms  of  renal  disease,  which  develop  rapidly. 

In  another  group  of  cases  some  special  symptom  only  may  be  com- 
plained of.  In  some  instances  it  may  be  gastric  catarrh,  in  some  eye- 
symptoms  alone  may  be  present,  while  in  others  hemicrania  or  other 
forms  of  headache  are  observed.  With  the  headache  there  is  usually 
vomiting.  Again,  we  may  have  constant  neuralgia  or  persistent  mus- 
cular rheumatism  as  the  only  symptom.  Nose-bleed  is  a  symptom 
which  may  be  the  only  indication  of  chronic  nephritis,  particularly  if 
the  epistaxis  occurs  frequently. 

In  other  cases  the  course  is  not  latent,  but  characterized  by  a  series 
of  attacks  at  varying  intervals. 

During  the  attacks  the  symptoms  resemble  the  acute  form  of  nephritis, 
with  acute  uraemia,  the  occurrence  of  dyspnoea  and  loss  of  appetite, 
nausea  and  vomiting.  The  tension  of  the  arteries  is  higher  at  the 
time  of  the  attacks.  The  urine  contains  albumin,  and  is  of  low  specific 
gravity  during  the  time  of  the  attack;  during  the  interval  the  albumin 
is  found  at  irregular  times. 

Spasmodic  dyspnoea  is  the  first,  and  sometimes  the  only  symptom  for 
a  long  time.  Later  the  renal  symptoms  become  pronounced,  pointing 
to  the  true  nature  of  the  disease.     The  renal  disease  is  often  not  sus- 


720  SPECIAL  DIAGNOSIS. 

pected  until  after  the  patient  has  had  an  attack  of  apoplexy.  The 
course  of  this  form  of  nephritis  is  varied  very  much  by  the  occur- 
rence of  complications,  notably  emphysema,  endocarditis,  or  cirrhosis 
of  the  liver. 

Suppurative  jSTephritis  (Abscess  of  Kidney).  Infectious  matter 
is  conveyed  to  the  kidney  either  through  the  blood,  as  in  pyaemia  and 
ulcerative  endocarditis  (rarely  dysentery  and  actinomycosis),  or  by  the 
ureters,  as  when  it  follows  pyelitis  or  cystitis.  A  wound  may  infect 
the  kidney  directly. 

Symptoms.  The  symptoms  are  those  of  primary  disease,  and  the 
affection  is  usually  only  recognized  post  mortem.  Or  the  symptoms 
are  merely  those  of  suppuration.  Pus  is  seen  in  the  urine  only  on 
rupture  of  the  abscess  into  the  pelvis  of  the  kidney. 

Tubercular  jSTephritis.  Fever,  emaciation,  ansemia,  and  pros- 
tration characterize  the  course  of  the  disease.  Tuberculosis  is  usually 
found  elsewhere.  There  may  be  no  other  symptoms.  Sometimes 
hydronephrosis  is  present.  A  tumor  is  often  present.  It  may  be  in 
the  loins,  or  may  be  in  front,  above,  and  a  few  inches  to  the  right  or 
left  of  the  umbilicus.  The  urine  is  normal  or  contains  pus  and  detri- 
tus or  even  bacilli.  The  finding  of  the  latter  is  necessary  often  to 
establish  a  diagnosis.  The  testicles  and  bladder  should  be  carefully 
examined  for  primary  tuberculosis. 

The  Degenerations. 

Degeneration  may  be  either  acute  or  chronic.  The  process  is  always 
secondary,  due  to  the  action  of  inorganic  poisons,  as  arsenic  or  phos- 
phorus, or  the  poison  of  infectious  disease,  or  is  produced  as  the 
effect  of  chronic  disease  of  the  organs,  or  by  disturbance  of  the  cir- 
culation. 

In  acute  degeneration  of  the  kidneys  the  urine  is  unchanged,  or  its 
quantity  is  diminished.  It  contains  a  little  albumin,  or  the  albumin 
is  present  in  large  amount  with  casts  and  blood-corpuscles. 

There  may  be  no  symptoms  except  changes  in  the  urine,  or  symp- 
toms of  uraemia  may  develop  at  once.  Dropsy  and  hypertrophy  of 
the  heart  do  not  occur. 

Chronic  degenerations  in  the  kidneys  follow  chronic  congestion,  or  are 
produced  by  alcoholism  or  syphilis.  They  occur  in  the  course  of  pul- 
monary phthisis,  of  chronic  suppuration,  and  syphilis;  they  may  de- 
velop in  the  course  of  gout  or  malarial  cachexia.  Symptoms :  In  the 
simpler  forms  there  may  be  no  clinical  symptoms  whatsoever.  In 
others  there  is  loss  of  flesh  and  strength,  the  development  of  anaemia, 
and,  in  rare  instances,  the  development  of  the  typhoid  state. 

The  changes  in  the  urine  vary.  It  may  be  abundant,  scanty,  or 
suppressed.  The  specific  gravity  is  not  changed,  but  albumin  and 
casts  are  found. 

Amyloid  degeneration  of  the  kidney  is  associated  with  similar  degen- 
ration  in  other  organs.  It  occurs  in  the  course  of  phthisis,  of  chronic 
suppurations,  of  syphilis,  of  chronic  dysentery,  and  is  thought  to 
occur  in  the  malarial  cachexia,  or  with  gout.     Symptoms :  The  degen- 


DISEASES  OF  THE  KIDNEYS.  721 

eration  may  be  present  without  clinical  symptoms.  If  symptoms  arise, 
they  are  due  to  the  anaemia  and  cachexia  that  attend  the  primary  dis- 
ease, and  to  the  involvement  of  the  other  organs  in  the  same  process,  as 
the  liver,  spleen,  and  intestines.  Purdy  says  dyspepsia  is  prominent  and 
diarrhceal  attacks  are  common.  The  liver  and  spleen  become  enlarged 
during  the  course  of  the  disease  in  the  majority  of  cases.  CEdema  may 
be  present,  although  it  is  more  frequently  absent.  Ursemia  is  of  rare 
occurrence.  In  the  uncomplicated  degenerations  there  is  no  hypertrophy 
of  the  left  ventricle,  and  albuminuric,  retinitis  is  a  rare  complication. 

The  Urine.  It  may  be  diminished,  normal,  or  increased,  usually 
the  latter;  it  varies  from  time  to  time  in  the  same  case,  depending  upon 
complicating  symptoms,  as  diarrhoea,  which  causes  diminished  amount 
of  urine.  It  is  usually  very  pale.  The  specific  gravity  is  not  con- 
stant. It  ranges  from  1008  to  1014.  Albumin  is  constantly  present, 
and  usually  in  considerable  amount.  Hyaline  casts  and  white  blood- 
cells  are  always  found.  When  other  casts  are  present  nephritis  prob- 
ably complicates  the  condition.  The  chief  distinctive  feature  of  the 
casts  is  their  large  size  and  hyaline  character. 

The  diagnosis  of  amyloid  disease  is  based  upon  the  presence  of  the 
cause;  changes  in  the  urine  ;  and  signs  of  similar  disease  in  other  organs. 

Sarcoma  and  Carcinoma  of  the  Kidney. 

Either  disease  may  be  primary  or  secondary.  Sarcoma  may  be  con- 
genital. The  tumor  may  occur  at  any  age,  but  is  relatively  common 
in  young  children.  In  older  persons  it  is  often  preceded  by  calculus. 
Symptoms :  In  some  instances  there  are  no  symptoms  during  life.  In 
others  the  disease  may  advance  considerably  before  it  presents  any  signs. 
If  symptoms  are  complained  of,  they  are  usually  limited  to  pain,  the 
occurrence  of  hematuria,  or  the  development  of  a  tumor.  The  pain 
is  dull  and  seated  in  the  lumbar  region.  It  may  be  neuralgic  in  char- 
acter; and,  indeed,  there  may  be  a  true  sciatica  with  paresis  of  the  leg 
from  pressure  of  the  tumor.  The  tumor  is  firm;  its  surface  is  smooth 
or  nodulated.  It  may  be  felt  in  the  loins,  and  in  front,  above  the 
umbilicus,  a  few  iuches  to  the  right  or  left  of  the  median  line ;  the 
descending  colon  lies  in  front  of  the  tumor.  The  hematuria  may  be 
constant  or  intermittent.      The  clots  of  blood  may  cause  renal  colic. 

The  general  symptoms  are  those  of  carcinoma.  A  marked  rapidity 
of  the  pulse  has  been  noted  in  several  cases.  In  girls  a  premature 
development  of  hair  on  the  pubes  and  in  the  axilla?  and  pigmentation 
of  the  skin  have  been  observed. 

The  tumor  must  be  distinguished  from  tumors  of  the  lymphatic 
glands,  of  the  liver,  of  the  spleen,  and  of  the  ovary.  It  must  not 
be  confounded  with  psoas  abscesses  and  perinephritic  abscesses,  which 
cause  a  tumor  in  the  lumbar  region. 

Cystic  Kidneys. 

1.  Congenital.  The  kidney  consists  of  a  small  mass  of  cysts  filled 
with  clear  fluid.  It  may  interfere  with  the  birth  of  the  child  on 
account  of  its  large  size. 

46 


722  SPECIAL  DIAGNOSIS. 

2.  Acquired.  The  cause  is  trauma  aud  obstruction  of  the  ureter. 
The  symptoms  are  those  of  a  fluctuating  renal  tumor.  The  urine  may 
be  normal  or  hsematuria  may  be  present. 

Horseshoe  Kidney.  There  are  usually  no  symptoms.  The  kid- 
ney can  sometimes  be  felt  through  the  abdomen  if  its  walls  are  relaxed, 
or  by  bimanual  examination. 

Hydronephrosis. 

Causes.  It  may  be  congenital.  Obstruction  of  ureter  by  stone; 
pressure  of  tumor;  twist,  as  in  movable  kidney:  exudates. 

Symptoms.  In  addition  to  the  symptoms  of  the  causal  condition  we 
have,  upon  the  development  of  hydronephrosis,  the  presence  of  a 
tumor,  arisiug  in  the  region  of  the  kidney  and  extending  toward  the 
middle  line.  Sometimes  fluctuation  can  be  detected;  often  it  cannot. 
Variations  in  size  of  the  tumor  may  occur  with  changes  in  amount  of 
urine  passed.  Puncture,  and  the  finding  of  a  fluid  with  elements  of 
urine  in  it,  are  valuable  means  of  diagnosis;  but  if  the  hydronephrosis 
is  old,  this  fails,  as  the  fluid  loses  its  urinary  character  and  cannot, 
for  instance,  be  distinguished  from  that  of  an  ovarian  cyst.  When 
on  one  side  the  urine  may  be  normal;  when  on  both  sides  it  is  dimin- 
ished; anuria  and  uraemia  may  occur.  If  pyelitis  is  present,  pyuria  is 
observed. 

Intermittent  hydronephrosis  is  associated  with  movable  kidney,  hence 
it  is  more  frequent  in  women.  It  is  characterized  by  the  development 
of  a  renal  tumor  with  variable  frequency,  and  with  pain,  nausea,  and 
vomiting.  At  the  same  time  the  urine  is  scanty.  In  a  few  hours  or 
days  there  is  an  increase  in  the  amount  of  urine  with  subsidence  of  the 
tumor. 

Pain  may  or  may  not  be  present.  Gastric  symptoms  are  very  com- 
mon. Either  constipation  or  diarrhoea  is  seen.  Hypertrophy  of  the 
left  ventricle  may  occur,  as  in  chronic  nephritis. 

Nephrolithiasis  (Renal  Calculus). 

Renal  calculi  vary  in  size  from  "  sand,"  through  "  gravel,"  to 
"  stones."  The  latter  may  be  from  the  size  of  a  cherry  to  one  large 
enough  to  fill  the  pelvis  of  the  kidney.  They  consist  usually  of  uric 
acid,  and  are  hard,  brownish-red  or  blackish,  crystalline,  and  the  larger 
ones  are  arranged  in  distinct  layers.  More  rarely  we  have  calculi  of 
calcium  oxalate,  extremely  hard  and  nodular.  Some  stones  have  alter- 
nate layers  of  the  two  salts;  others  consist  of  phosphates,  but  usually 
the  inside  is  of  uric  acid  or  calcium  oxide,  the  phosphates  having  been 
deposited  after  the  urine  became  alkaline.  Very  rare  forms  are  of 
cystin,  xanthin,  indigo,  etc. 

Symptoms.  When  stones  are  very  small  (sand)  there  are  no  symp- 
toms except  perhaps  occasional  pain  in  the  lumbar  region.  When 
larger  they  attempt  to  pass  the  ureter  or  irritate  the  pelvis  and  cause 
renal  colic.  The  latter  comes  on  suddenly,  is  very  intense,  and  radiates 
from  the  loin  and  right  or  left  centre  of  the  abdomen  down  to  the 


DISEASES  OF  THE  KIDNEYS.  723 

bladder,  testicle,  and  thigh.  Collapse  occurs  in  severe  cases.  The 
urine  may  be  lessened  in  amount,  or  suppressed  if  both  sides  are  ob- 
structed. It  may  contain  blood  and  pus.  The  attack  lasts  from  a 
few  hours  to  several  days.  Between  paroxysms  there  may  be  constant 
pain,  and  the  urine  contain  blood,  and  sometimes  pus  and  pelvic 
epithelium;  at  other  times  the  urine  is  clear  and  normal.  Pyelitis, 
pyonephrosis,  and  hydronephrosis  may  develop. 

The  stone  usually  develops  in  the  pelvis  of  the  kidney — not  in  the 
kidney  itself.  A  stone  may  remain  fixed  in  the  pelvis  and  produce 
no  symptoms,  or  only  those  of  gastric  disturbances,  catarrh  of  the 
bladder,  and  pyelitis. 

Diagnosis.  It  must  be  distinguished  from  lumbago,  perinephritic 
abscess,  hepatic  colic,  and  gastralgia.  Kelley,  after  catheterization  of 
the  ureters,  aspirates  the  ureters  and  thereby  brings  down  fragments 
of  calculi.  He  also  explores  the  ureters  with  hard-rubber  bougies 
tipped  with  wax.  He  can  determine  the  presence  of  calculi  by  the 
markings  on  the  tip  of  the  bougie. 

Pyelitis.     Pyonephrosis. 

Causes.  Rarely  primary;  usually  secondary.  Severe  infectious  dis- 
eases (typhus,  variola,  diphtheria,  pyaemia);  toxic  substances  ingested 
(cantharides,  etc.);  chronic  nephritis;  inflammation  of  the  bladder 
or  ureter;  strictures  of  the  ureter  or  urethra;  hypertrophy  of  the 
prostate;  spinal  palsies  of  the  bladder;  calculus;  parasites;  blood-clots. 

Symptoms.  The  Urine.  Pus  in  the  urine  with  pelvic  epithelium — 
although  it  is  not  safe  to  base  a  diagnosis  on  the  presence  of  the  latter; 
casts  of  the  canals  opening  into  the  pelvis  are  more  characteristic;  epi- 
thelial casts,  and  casts  containing  micro-organisms.  The  urine  is  often 
increased,  acid,  and  contains  pus  and  albumin,  rarely  blood.  In  all 
forms  of  pyaemia  above  the  bladder  Kelley  withdraws  the  pus  by 
catheterization  and  suction.  He  allows  the  catheters  to  remain  from 
ten  minutes  to  four  or  five  hours,  in  order  to  estimate  the  functional 
power  of  each  kidney.  Of  course,  the  pus  is  studied  microscopically 
and  bacteriologically.  Pain  in  the  region  of  the  kidney,  often  severe, 
is  complained  of,  although  it  may  be  absent.  When  present,  it  is 
often  of  a  tearing  character.  Tumor.  A  tumor  is  often  present.  It 
is  most  prominent  in  the  loin  or  in  the  abdomen.  In  the  latter  the 
mass  can  be  felt  two  inches  to  either  side  of  the  umbilicus,  usually 
above  the  transverse  line. 

Fever  is  irregular,  remitting,  or  septic.  If  the  bladder  is  healthy, 
its  symptoms  fail  to  aid  in  diagnosis. 

Perinephritic  Abscess. 

Causes.  Trauma;  abscess  in  the  kidney;  pyelitis  (either  simple, 
calculous,  tubercular,  cancerous,  echinococcal);  abscess  in  the  neighbor- 
ing organs,  as  the  liver  or  lungs;  Pott's  disease;  actinomycosis;  pelvic 
cellulitis;  appendicitis.  It  also  occurs  as  a  primary  disease  in  appar- 
ently healthy  individuals,  or  after  infectious  diseases. 


724  SPECIAL  DIAGNOSIS. 

Symptoms.  The  secondary  forms  have  symptoms  of  the  primary  dis- 
ease, and,  later,  swelling  and  pain  in  the  renal  region. 

Primary  form.  Chills  and  fever,  pain,  difficulty  in  defsecation.  The 
general  condition  suffers.  Finally,  in  all  cases,  there  is  the  formation 
of  a  swelling  in  the  lumbar  region,  at  first  hard;  then  oedema  of  the 
skin  follows,  and  fluctuation  is  detected.  The  abscess  may  descend 
and  point  above  Poupart's  ligament.  It  may  press  upward  and  cause 
dyspnoea.  Great  tenderness  and  pain  in  the  region  of  swelling  may 
arise,  and  the  pain  may  radiate  to  the  leg.  Irregular  septic  fever  and 
chills  appear.  The  urine  is  not  generally  changed  unless  some  commu- 
nication with  the  pelvis  or  ureter  has  formed.  The  patient  lies  on  his 
back,  turned  toward  the  affected  side.  The  knee  and  hip  of  this  side 
are  flexed  and  the  thigh  rotated  outward.  The  affection  may  simulate 
coxitis  aud  appendicitis. 

Parasites. 

1.  Echinococcus.  Comparatively  rare.  Usually  there  are  no  symp- 
toms until  a  tumor  is  felt.  Then  pain  gradually  develops.  The  cyst 
may  open  into  the  pelvis  of  the  kidney,  and  cyst  or  scolices  be  dis- 
charged, with  colic. 

Pyelitis  and  cystitis  may  also  develop. 

Echinococcus  cyst  may  inflame  and  lead  to  general  pyaemia.  Punc- 
ture of  the  discovered  tumor  is  otherwise  the  only  means  of  diagnosis. 
It  must  be  differentiated  from  hydronephrosis  and  ovarian  tumors. 
Puncture  is  necessary. 

2.  Distoma  Haematobium.  Common  in  Egypt  and  Abyssinia.  Eggs 
collect  in  great  masses  in  the  urinary  passages,  and  lead  to  inflamma- 
tion, ulcers,  stenosis,  etc.  Eggs  found  in  the  urine  alone  make  the 
diagnosis  possible. 

3.  Strongylus  Gigas.  Very  rare.  Symptoms  of  pyelitis.  (The 
parasite  is  of  the  size  of  an  earth-worm.) 

4.  Filaria  Sanguinis  Hominis.  Causes  chyluria.  Embryos  may 
be  found  in  the  urine. 

Movable  Kidney. 

Movable  kidney  is  usually  seen  in  women  after  the  age  of  forty 
years,  who  did  physical  work  or  had  many  children.  Adult  males 
and  single  women  do  not  escape.  Its  occurrence  is  frequently  pre- 
ceded by  a  history  of  unusual  lifting  or  strain,  followed  by  tearing  or 
dragging  sensations  in  the  abdomen.  Pain  may  continue  for  several 
weeks  after  the  injury,  and  then  subside  and  the  occurrence  be  for- 
gotten, or  subjective  sensations  may  continue. 

The  symptoms  that  arise  are  due  to  the  local  dragging  or  pulling  of 
the  kidney  on  its  bloodvessels  and  nerves,  or  to  reflex  symptoms,  or 
to  pressure  upon  adjacent  organs. 

The  pain  that  attends  movable  kidney  is  usually  referred  to  the  right 
or  left  of  the  median  line;  sometimes  to  the  hypogastrium.  It  may 
be  constant,  dull,  and  aching  in  character.  Paroxysms  may  arise  in 
the  course  of  the  constant  pain,  or  a  paroxysm  alone  may  take  place. 


DISEASES  OF  THE  KIDNEYS.  725 

The  paroxysms  continue  for  three  or  four  days,  during  which  time 
other  subjective  symptoms  are  more  pronounced.  The  attacks  are 
known  as  DieWs  crises,  as  he  described  them.  Nausea  may  attend 
the  paroxysms,  or  be  more  or  less  constant.  Sometimes  vomiting 
takes  place.  The  great  pain  is  associated  with  swelling  and  tender- 
ness of  the  kidney.  The  severe  pain,  vomiting,  and  local  tenderness 
may  simulate  peritonitis. 

In  addition  to  pain  a  dragging  sensation  is  experienced;  the  patient 
may  be  aware  of  the  presence  of  a  tumor  or  lump  in  the  abdomen,  as 
well  as  of  its  movability.  The  reflex  symptoms  are  chiefly  referable 
to  the  nervous  system.  Emotional  disturbance  is  observed  when  the 
organ  is  out  of  its  capsule.  Hysteria  may  be  present.  There  are  often 
depression  of  spirits  and  often  hypochondriasis.  Jaundice  may  occur 
from  pressure,  and  the  intestine  may  be  occluded. 

The  urinary  symptoms  are  of  interest.  When  the  local  pain  and 
other  symptoms  are  more  pronounced  the  urine  may  be  scanty.  In 
one  case  it  was  reduced  to  sixteen  ounces  in  twenty-four  hours.  At 
the  same  time  that  the  urine  is  scanty  hydronephrosis  will  develop. 
It  will  be  referred  to  again.  As  the  kidney  slips  back  into  its  bed  the 
twisting  of  the  ureter  is  relieved,  and  copious  discharges  of  urine  take 
place.     Palpitation  of  the  heart  is  a  common  reflex  symptom. 

Objective  Symptoms.  The  abdominal  walls  are  usually  relaxed,  and 
may  or  may  not  contain  a  large  amount  of  fat.  On  palpation  a  tumor 
can  be  found  to  the  right  or  left  of  the  median  line,  freely  movable 
and  changing  its  position  with  that  of  the  patient.  If  the  tumor  is 
situated  on  the  right  side,  it  may  be  in  close  proximity  to  the  liver,  or 
be  felt  opposite  the  umbilicus,  or  often  in  the  iliac  region.  When  near 
the  liver,  by  careful  palpation  the  fingers  can  be  introduced  between 
the  border  of  the  liver  and  the  mass.  Usually  it  does  not  move  with 
respiration,  but  sometimes  it  is  found  to  do  so.  On  the  left  side  it 
may  be  as  high  up  as  the  margin  of  the  ribs.  It  is  generally  felt  in 
the  mid-clavicular  line,  a  little  above  the  level  of  the  umbilicus.  It 
is  likewise  movable.  On  palpation  the  tumor  is  found  to  be  of  the 
shape  of  the  kidney,  firm  in  character,  and  at  times  quite  painful. 
The  hilus  of  the  kidney  and  the  vessels  going  to  it  can  at  times  be 
felt.  Palpation  frequently  causes  nausea,  and  may  excite  an  attack  of 
palpitation  or  pronounced  nervous  symptoms. 

In  a  case  recently  under  the  writer's  care  the  woman,  aged  fifty- 
five  years,  would  experience  pain  in  the  abdomen  about  once  a  month, 
to  the  right  of  and  above  the  umbilicus.  At  times  nausea  and  vomit- 
ing accompanied  the  attacks,  at  other  times  marked  depression  or  hys- 
teria. Anuria  always  occurred  and  continued  for  a  variable  time)  not 
longer  than  five  days.  With  one  of  the  paroxysms  a  tumor  was 
found  in  the  region  of  the  gall-bladder,  movable  with  respiration,  but 
distinctly  defined  from  the  liver  by  placing  the  fingers  between  the 
lobe  and  kidney.  It  moved  with  each  change  of  position  of  the  patient, 
and  at  first  the  hilus  could  be  distinctly  felt.  As  the  pain  continued 
the  anuria  persisted,  and  a  marked  change  in  the  tumor  was  observ- 
able. It  gradually  increased  in  size,  and  a  portion  of  it  fluctuated; 
it  was  round  and  partook  of  the  character  of  a  cyst.     The  fluctuation 


726  SPECIAL  DIAGNOSIS. 

was  detected  by  placing  the  hand  on  the  tumor  in  front  and  pressing 
firmly  toward  the  other  hand  placed  in  the  loin  above  the  pelvis. 
When  the  anuria  disappeared  a  copious  discharge  of  urine  took  place 
and  the  swelling  subsided. 

Movable  kidney  may  be  confounded  with  tumor  of  the  gall-bladder, 
tumor  of  the  pylorus,  and  with  tumors  in  the  pelvis.  It  is  not  likely 
to  be  confounded  with  an  omental  tumor,  carcinoma,  or  tuberculosis, 
because  the  phenomena  of  these  processes  are  not  present  and  ascites 
does  not  occur,  nor  is  there  rise  of  temperature,  as  in  many  cases  of 
tuberculosis.  As  pointed  out  by  Henry  Morris,  tumor  of  the  gall- 
bladder and  movable  kidney  are  frequently  of  conjoint  occurrence. 
Movable  kidney  is  distinguished  by  the  absence  of  previous  history  or 
of  symptoms  or  signs  indicating  disease  of  the  gall-ducts.  If  jaundice 
is  present,  it  is  not  so  intense  as  in  tumors  of  the  gall-bladder. 
While  the  gall-bladder  is  movable,  it  is  not  so  distinctly  so  as  movable 
kidney.  The  gall-bladder  moves  in  an  arc  of  a  circle,  the  centre  of 
which  is  at  the  edge  of  the  right  lobe  of  the  liver.  It  can  be  pushed 
further  to  the  left  than  the  right,  but  never  downward  as  a  movable 
kidney.  Moreover,  the  gall-bladder  is  always  palpable,  the  movable 
kidney  cannot  always  be  felt.  The  gall-bladder,  if  it  contain  calculi, 
is  very  hard  compared  to  the  kidney.     Anuria  does  not  occur. 

The  kidney  tends  to  spring  back  to  its  place  in  the  loin;  the  gall- 
bladder to  the  anterior  part  of  the  abdomen.  Even  if  the  gall-bladder 
is  enlarged,  the  kidney  can  be  felt  by  bimanual  palpation;  while  the 
opposite  does  not  obtain.  In  cancer  of  the  pylorus  the  emaciation 
and  anaemia  are  more  pronounced  than  in  movable  kidney.  The 
vomiting,  usually  characteristic  in  that  affection,  and  the  physical 
signs  of  dilated  stomach,  can  be  made  out.  Tumors  of  the  pelvic 
organs  are  determined  by  examination  according  to  the  usual  methods. 


CHAPTER   VIII. 

DISEASES  OF  THE   BLOOD  AND  DUCTLESS  GLANDS. 
Inspection  of  the  Blood. 

The  blood  consists  of  corpuscles  and  serum.  The  corpuscles  are 
four  :  (1)  red  blood-cells;  (2)  nucleated  red  blood-cells;  (3)  blood- 
plaques  ;  (4)  leucocytes. 

The  ordinary  red  blood-cells  measure  -32V-3-  inch;  the  leucocytes, 
-jJg-Q-  inch.  In  an  adult  man  the  red  cells  number  from  5,000,000 
to  5,500,000  to  the  cubic  millimetre;  in  an  adult  woman  the  number 
is  usually  less,  being  from  4,500,000  to  5,000,000.  There  are  8000 
to  10,000  leucocytes  in  a  cubic  millimetre  of  blood,  or  1  to  350-600 
red  blood-cells. 

Varieties  of  Leucocytes.  In  the  normal  blood  there  are  found  the 
following  varieties  of  leucocytes:  1.  Small  mononuclear  forms,  which 
are  cells  about  the  size  of  a  red  blood-corpuscle  and  have  a  round,  large, 
deeply  staining  nucleus,  surrounded  by  a  narrow  rim  of  non-granular 
protoplasm.  These  are  known  as  lymphocytes.  2.  Large  mono- 
nuclear leucocytes  several  times  as  large  as  the  foregoing.  They  have  a 
round  or  oval  nucleus  with  a  relatively  larger  amount  of  non-granu- 
lated protoplasm.  3.  Transitional  forms  which  resemble  the  last 
named,  except  that  the  nuclei  are  indented  or  "S  "-shaped.  4. 
Poly  nuclear  leucocytes.  These  are  usually  about  the  size  of  the  fore- 
going variety,  but  they  may  be  somewhat  smaller.  The  nuclei  are 
long  and  irregular  and  stain  deeply.  The  protoplasm  contains  granules 
that  stain  by  a  combination  of  both  basic  and  acid  dyes,  but  by 
neither  alone.  The  cells  are  therefore  called  "neutrophiles."  5. 
Leucocytes  similar  to  the  last  form,  except  that  their  protoplasm  con- 
tains highly  refracting  granules  that  are  stained  by  acid  dyes  alone. 
For  this  reason  they  are  usually  called  "  eosinophils."  The  propor- 
tion of  each  variety  in  the  normal  blood  is  fairly  constant;  lymphocytes, 
15  to  25  per  cent.;  polynuclear,  65  to  80  per  cent. ;  mononuclear  and 
transitional  forms,  6  per  cent.,  and  eosinophiles,  2  per  cent,  or  less. 
(Plate  IX.) 

Inspection  of  the  blood  may  be  (1)  with  the  eye  alone,  or  (2)  with 
special  instruments. 

1.  Ixspectiox  with  the  Unaided  Eye.  This  gives  but  little 
information.  It  serves  to  distinguish  bright- red  arterial  blood  from 
darker  venous  blood,  and  also  indicates  when  arterial  blood  has  become 
deficient  in  oxygen  from  any  of  the  causes  of  venous  engorgement  and 
cyanosis.  In  chlorosis  and  hydremias  the  blood  is  pale,  as  though 
mixed  with  water,  while  in  severe  leukaemias  it  has  a  slight  milky  tinge. 
On  the  other  hand,  in  carbonic-oxide  poisoning  the  blood  becomes  of  a 
brighter  red,  while  in  poisoning  with  chlorate  of  potash  and  anilin, 


728 


SPECIAL  DIAGNOSIS. 


and  in  grave  cases  of  poisoning  with  nitrobenzol  and  hydrocyanic  acid? 
it  is  brownish-red  or  chocolate-colored. 

2.  Inspection  with  Special  Instruments.  These  are  the  micro- 
scope, the  haernoglobinorneter,  the  hsemocytometer.  The  examination 
is  made  to  determine  (1)  if  the  red  cells  and  the  white  cells  respectively 
are  increased  or  diminished,  (2)  if  they  have  changed  their  form  (red 
cells),  or  (3)  if  their  morphology  has  changed  (white  cells). 

The  Microscope.  Inspection  with  the  microscope  reveals  red  and 
white  blood-cells  and  blood -plaques. 

The  microscope  is  also  essential  for  blood-counting,  the  study  of 
cover-glass  preparations  according  to  Ehrlich's  methods,  and  for 
examinations  for  parasites. 

Hcemoglobinometers.  Gowers'  s  hsemoglobinometer  (Fig.  140)  consists 
of  (1)  a  closed  tube,  d,  containing  coloring-matter  representing  the  color 
human  blood   should   have  normally,  if  diluted  one  hundred  times; 

Fig.  140. 


Gowers's  hsemoglobinometer. 

(2)  a  corresponding  empty  tube,  c,  graduated  in  an  ascending  scale 
from  10  to  120;  (3)  a  capillary  glass  tube,  b,  marked  at  20  cubic  milli- 
metres ;  a  small  guarded  lancet,  f,  and  a  small  bottle  with  a  pipette 
stopper,  a,  for  distilled  water.  A  few  drops  of  distilled  water  are 
first  placed  in  the  empty  tube  c  to  prevent  the  coagulation  of  the 
blood,  which  would  occur  if  the  blood  were  first  put  in  the  tube.  The 
finger  or  lobe  of  the  ear,  previously  cleansed  with  water  and  ether,  is 
then  deeply  stabbed  with  the  lancet,  so  that  the  blood  will  flow  freely, 
care  being  taken  to  avoid  squeezing  the  punctured  part;  20  cubic 
millimetres  of  blood  are  then  quickly  drawn  up  in  the  capillary  tube 
and  at  once  blown  into  the  graduated  tube,  wThich  is  shaken  to  allow 
the  blood  to  become  diffused  in  the  water.  The  tubes  containiug  the 
standard  coloring-matter  and  the  diluted  blood  are  now  held  up,  side 
by  side,  against  a  sheet  of  paper,  and  more  distilled  water  added,  drop 
by  drop,  with  repeated  shakings,   until  the  colors  in  the  two  tubes 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       729 

match.  The  height  to  which  the  column  of  diluted  blood  and  water 
has  risen  in  the  graduated  tube  represents  the  percentage  of  hemo- 
globin contained  in  the  blood  tested. 

Fleischl's  hsemoraeter  consists  of  a  small  metal  table  with  an  aper- 
ture in  the  middle,  under  which  is  a  reflector  made  of  plaster-of-Paris. 
The  opening  is  occupied  by  a  small  well  having  a  glass  bottom  and 
divided  into  two  equal  compartments.  The  standard  color  of  the 
blood  at  different  dilutions  is  represented  by  a  wedge  of  glass,  colored 
with  Cassius  purple,  which  is,  of  course,  pale  iu  color  at  the  extreme 
edge  and  deepens  in  intensity  with  its  thickness.  This  wedge  of  glass 
is  moved  under  the  table  by  a  rack  and  pinion,  and  is  accompanied 
by  a  graduated  scale.  One-half  of  the  well  receives  simply  the  light 
from  the  plaster-of-Paris  reflector,  while  the  other  rests  upon  the 
ruby  glass  and  obtains  light  through  it;  the  light  from  a  candle,  gas- 
jet,  or  oil-lamp  must  be  used.  A  small  pipette  and  several  capillary 
tubes  about  f  iuch  in  length  and  mounted  on  slender  metal  handles 
are  employed  to  obtain  the  necessary  amount  of  blood;  each  one  of 
them  will  hold  enough  normal  blood  to  produce,  when  properly  diluted, 
a  color  corresponding  to  that  of  the  ruby  glass  at  the  100  mark.  For 
use,  one  end  of  a  capillary  tube  is  carefully  lowered  upon  a  drop  of 
blood  which  immediately  fills  it;  the  tube  is  then  at  once  washed  in  one 
of  the  compartments  of  the  well,  which  contains  some  water.  The 
compartments  are  now  equally  filled  with  water,  and  the  well  so  placed 
that  the  side  containing  blood  receives  yellow  light,  as  from  a  candle, 
while  the  other  receives  light  through  the  wedge  of  glass.  The  glass 
is  now  moved  by  the  rack  and  pinion  until  the  intensity  of  the  color 
in  the  two  compartments  is  the  same,  and  the  percentage  is  then  read 
off  through  the  small  opening  behind  the  well. 

Both  Gowers's  and  Fleischl's  instruments  are  about  equally  accurate, 
and  both  are  graduated  for  a  higher  percentage  of  hsemoglobin  than  is 
the  average  with  Americans,  which  may  be  as  low  as  96  per  cent. 

Hoemocytometers.  The  hsemocytometers,  or  blood-counters,  most  fre- 
quently used  in  this  country  are  those  of  Gowers  and  Thoma-Zeiss. 

Gowers's  instrument  (Fig.  141)  consists  (1)  of  a  small  pipette,  A, 
which,  when  filled,  holds  exactly  995  cubic  millimetres;  it  is  for  meas- 
uring the  diluting  fluid;  (2)  a  capillary  tube,  b,  graduated  for  5  cubic 
millimetres;  (3)  a  small  glass  jar,  d,  in  which  the  dilution  is  made;  (4) 
a  small  glass  stirrer,  e,  for  mixing  the  blood  and  diluting  fluid  in  the 
jar;  (5)  a  small  lancet,  f  ;  (6)  a  brass  stage-plate,  c,  carrying  a  glass 
slip  on  which  is  a  cell  one-fifth  of  a  millimetre  deep.  The  bottom  of 
the  cell  is  divided  into  one-tenth  millimetre  squares.  On  the  top  of 
the  cell  rests  the  cover-glass,  which  is  kept  in  place  by  the  pressure  of 
two  springs  proceeding  from  the  ends  of  the  stage-plate;  995  cubic  milli- 
metres of  the  diluting  fluid  are  measured  and  blown  into  the  mixing- 
jar;  then  5  cubic  millimetres  of  blood  are  added  and  the  two  thoroughly 
mixed.  A  small  drop  of  the  mixture  is  then  placed  upon  the  cell,  the 
cover-glass  gently  adjusted  and  held  in  place  by  the  two  springs. 
From  five  to  ten  minutes  should  be  allowed  to  elapse,  so  that  the  cor- 
puscles will  have  time  to  settle  to  the  bottom  of  the  cell.  The  stage- 
plate  is  then  placed  under  a  microscope,  and  the  number  of  red  blood- 


730 


SPECIAL  DIAGNOSIS. 


cells  in  ten  squares  counted.  This  number  multiplied  by  10,000  gives 
the  number  in  a  cubic  centimetre  of  pure  blood.  It  is  better  to  count 
a  large  number  of  squares,  take  the  average,  and  multiply  by  100,000. 


Fig.  HI. 


Hsemoevtometer  of  Gowers. 


This  number  is  the  product  of  the  dilution  (200)  by  the  square  surface 
of  the  cells,  100  (10x10),  and  again  by  5,  the  depth  of  the  cell: 
200  X  100  X  .5  =  100,000.  To  facilitate  seeing  the  fine  lines  marking 
the  squares,  a  soft  black  lead-pencil  should  be  gently  rubbed  over  them 


Fig.  142. 


Thoma-Zeiss  blood-counting  apparatus. 


before  the  drop  of  diluted  blood  is  placed  on  the  cell.  Counting  of  the 
white  cells  is  made  much  easier  if  the  diluting  fluid  is  colored  a  pale 
violet  with  a  very  small  quantity  of  gentian-violet.      The  white  cells 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       731 


then  appear  a  distinct  blue,  while  the  red  cells  are  unaltered.  As 
diluting  fluids,  a  1  per  cent,  solution  of  common  salt,  or  a  2J  per  cent, 
solution  of  bichromate  of  potash,  as  recommended  by  Daland,  may  be 
employed;  or  Toison's  fluid  can  be  used.  The  latter  is  made  up  as 
follows  :  Distilled  water,  160  c.c. ;  glycerin,  30  c.c. ;  sulphate  of  soda, 
8  c.c;  chloride  of  soda,  1  gramme;  methyl- violet,  .025  gramme. 

Another  hamiocytometer  is  the  Thoma-Zeiss  (Fig.  142).  It  is  pre- 
ferred by  most  clinicians.  It  consists  of  a  heavy  glass  slip  (a)  in  the 
middle  of  which  is  a  cell  (B)  exactly  ^  millimetre  in  depth.  The  cell 
is  limited  at  the  periphery  by  a  circular  gutter  to  prevent  fluid  placed 
upon  the  cell  from  flowing  beyond  it  between  the  slip  and  cover-glass. 
The  floor  of  the  cell  is  ruled  into  squares  whose  sides  are  -^  mm. 
Double  lines  mark  out  large  squares  each  containing  sixteen  small 
squares.  Thick,  carefully  ground  cover-glasses  (Z>)  are  provided  in 
the  case.  The  ordinary  Potain  melangeur  (S)  is  used  to  measure 
and  mix  the  blood.  It  consists  of  a  capillary  tube  the  upper  portion 
of  which  is  blown  into  a  chamber  (E)  holding  100  c.mrn.  The  stem 
of  the  tube  is  graduated  at  0.5  and  at  1  c.mm. 

To  use  the  instrument  a  drop  of  blood  is  obtained  from  the  finger 
or  lobe  of  the  ear,  the  point  of  the  capillary  tube  is  inserted  into  the 
drop,  and  blood  sucked  up  to  the  mark  1  c.mm.  The  point  of  the  tube 
is  then  quickly  wiped  free  from  excess  of  blood,  and  inserted  into  the 
diluting  fluid,  which  is  drawn  up  to  the  level  of  the  mark  101.  The 
proportion  of  blood  and  diluting  fluid  is  then  1  to  100  c.mm.  The 
blood  and  diluting  fluid  are  now  thoroughly  mixed.  The  diluting  fluid 
in  the  stem  of  the  melangeur  is  now  blown  out,  and  a  drop  of  the  blood- 
mixture  placed  on  the  cell.  The  cover-glass  is  adjusted  carefully  to 
avoid  bubbles  and  to  prevent  the  escape  of  the  fluid  between  it  and 
the  slip.  The  cover-glass  is  now  pressed  firmly  down  until  Newton' s- 
color-rings  appear,  and  then  the  slip  is 
allowed  to  stand  for  five  or  ten  minutes, 
until  the  corpuscles  have  settled  to  the 
bottom  of  the  cell. 

The  cell  is  ruled  into  400  small  squares, 
groups  of  sixteen  squares  being  separated 
by  double  lines.  The  surface  of  a  square 
is  -f^-Q  square  millimetre,  and  the  depth  of 
the  cell  being  -^  millimetre,  the  space 
overlying  each  square  is  -nrVir  °f  a  cu°ic 
millimetre.  In  estimating  the  number  of 
corpuscles  in  a  cubic  millimetre  of  blood 
multiply  the  number  of  corpuscles  counted 
in  all  the  squares  by  4000,  and  the  pro- 
duct by  the  dilution,  which  is  to  1  to  100 

or  1  to  200,  according  as  1  or  0.5  c.mm.  of  blood  has  been  used.  The 
last  product  is  now  to  be  divided  by  the  number  of  squares  which  have 
been  included  in  the  count,  the  quotient  being  the  number  of  corpus- 
cles in  a  cubic  millimetre  of  blood.  The  results  are  accurate  in  propor- 
tion to  the  care  exercised  in  the  measurement  of  the  blood  and  diluting 
fluid,  and  especially  in  proportion  to  the  number  of  squares  counted. 


Fig. 

143 

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Appearance  of  blood  iu  the  Thoma- 
Zeiss  cell. 


732  SPECIAL  DIAGNOSIS. 

In  the  estimation  of  white  blood-cells  the  pipette  made  by  Zeiss  is 
employed.  In  this  instrument  the  blood  is  diluted  ten  times  by  a  solu- 
tion of  one  part  of  a  J  per  cent,  aeetic-acid  solution  to  ten  parts  of 
distilled  water.  By  means  of  this  solution  red  cells  are  dissolved  and 
the  nuclei  of  the  white  cells  are  rendered  distinct  and  easy  of  recogni- 
tion. Toison's  fluid,  mentioned  above,  may  also  be  used.  The  ordi- 
nary Thoma-Zeiss  slide  is  employed  and  the  average  number  of  white 
cells  in  each  small  square  is  multiplied  by  40,000.  To  obtain  accurate 
results  four  entire  fields  should  be  counted. 

The  Hcematohrit  is  an  instrument  devised  for  the  estimation  of  the 
percentage-volume  of  red  corpuscles  by  means  of  centrifugal  force. 
In  Daland's  article  will  be  found  a  full  description  of  the  instrument, 
and  from  the  same  article  the  following  method  of  using  it  is  abstracted : 
■"The  finger  or  ear  and  apparatus  are  prepared  as  above.  An  incision 
is  made  deep  enough  to  produce  a  good-sized  drop  of  blood.  This  is 
drawn  into  a  hsematokrit-tube  by  means  of  suction  through  an  attached 
rubber  tube,  one  finger  being  placed  over  the  free  end  when  the  rubber 
tube  is  removed  to  prevent  the  loss  of  blood.  The  filled  tube  is  then 
placed  in  the  frame  of  the  hseniatokrit  and  a  second  prepared  exactly 
as  the  first.  The  larger  wheel  is  then  rapidly  rotated  for  two  minutes 
at  seventy-seven  turns  of  the  handle-crank  per  minute  (giving  alto- 
gether 20, 000  rotations  of  the  frame),  and  the  result  read  from  the  scale 
multiplied  by  2  gives  the  percentage-volume.  It  has  been  found  by 
experimenting  that  each  division  upon  the  scale  of  the  hgematokrit- 
tube  represents  100,000  corpuscles."  This  procedure  is  not  available 
for  the  determination  of  the  volume  of  leucocytes  unless  the  number 
exceeds  20,000,  at  and  above  which  number  an  approximate  estimate 
may  be  readily  determined.  A  distinct  white  band  appearing  between 
the  red  cells  and  the  clear  fluid,  having  the  width  of  one  line,  may  be 
considered  as  representing  from  15,000  to  20,000  leucocytes. 

Oligocythemia.  Oligocythemia  is  the  name  applied  to  a  diminution 
in  the  number  of  red  blood-cells,  from  whatever  cause.  It  is  usually 
associated  with  oligochromcemia  (deficiency  of  haemoglobin),  which, 
however,  in  idiopathic  anaemia  is  absolute,  not  relative.  Marked 
oligocythemia  can  be  detected  with  the  microscope  alone,  and  can  be 
estimated  accurately  with  the  haemocytometer  or  hsematokrit  (see  Fig. 
141). 

Leucocytosls.  Leucocytosis  is  a  temporary  increase  in  the  number  of 
white  blood-cells  of  the  same  morphological  varieties  as  in  health 
with  an  excess  of  the  poly  nuclear  forms.  Such  increase  may  be  physio- 
logical or  pathological,  as  indicated  in  the  following  : 

Physiological  Leucocytosis.     (1)  Pregnancy  (14,000  and  upward) ; 

(2)  during  digestion  (from  1000  to  7000  above  normal;  more  in  chil- 
dren); (3)  newborn  (12,000). 

Pathological  Leucocytosis.     (1)  Leukaemia;  (2)  pernicious  anaemia  ; 

(3)  chlorosis  ;  (4)  diseases  of  lymphatic  glands  ;  (5)  disease  accompanied 
by  exudations,  as  pleurisy,  pericarditis,  meningitis,  polyarthritis,  and 
especially  croupous  ■pneumonia;  (6)  inflammatory  condition  associated 
with  exudation;  (7)  many  acute  infectious  diseases,  as  morbilli,  varicella, 
variola,  vaccinia,  epidemic  cerebrospinal  meningitis;  (8)  after  hemor- 


PLATE    VII. 
FIG.  i. 


r 


3} 


\  tiff*      >■■  *. 

I 


Blqod  from  Case  of  Pneumonia,  showing  Leucocytes. 

(Oc.  4,  ob.  Via  immersion.)    Drawn  by  J.  D.  Z.  Chase. 


FIG.  2. 


® 


3l  -       j& 


y  ...  " 


*u* 


■ 


Normal  Blood,  showing  Rouleaux  and  Leucocytes. 
Or    i   ob.  Via  immersion.)    Drawn  by  J.  D.  Z.  Chase. 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       733 

rhage  and  (9)  just  before  death,  leukocytosis  of  agony.  But  it  is  not 
found  in  uncomplicated  cases  of  (1)  influenza  (Boston  Medical  and 
Surgical  Journal,  March  22,  1894);  (2)  uncomplicated  cases  of  typhoid 
and  typhus  fever;  (3)  tuberculosis  when  not  associated  with  cavity-for- 
mation or  hyperplasia  of  lymphatic  glands  (Stein  and  Erbman,  Deutsch. 
Archiv.  f.  klin.  31ed.,  Bd.  56);  (4)  infection  by  pyogenic  cocci;  (5) 
many  forms  of  carcinoma  and  sarcoma,  gastric  ulcer,  and  benign 
pyloric  stenosis  (Schreuger,  Zeltschr.f.  klin.  Med.,  1895,  27,  475). 

Diagnostic  value.  The  value  in  diagnosis  of  determining  the  pres- 
ence of  leucocytosis  is  great.  Its  absence  excludes  the  first  series  of 
cases;  its  presence  the  last.  If  leucocytosis  is  present  in  the  course  of 
or  convalescence  from  typhoid  fever,  it  points  to  a  complication,  as 
thrombosis.  A  post-febrile  rise  from  a  complication  may  be  distin- 
guished from  a  true  relapse  by  an  increase  of  the  white  cells. 

It  is  best  determined  with  a  hsemocytometer.  Dry  preparations 
according  to  Ehrlich'  s  method  are  necessary  for  a  study  of  the  vari- 
ous forms  of  leucocytes  (see  under  Leucocythaemia,  page  743,  and 
Plate  IX.). 

Neusser's  Granules.  Neusser  has  described  perinuclear  basophilic 
grauulations  in  the  leucocytes,  which  are  demonstrated  by  staining 
the  blood  with  the  following  modification  of  Ehrlich' s  triple  stain  : 

Saturated  aqueous  solution  of  acid  fuchsiu 50  c.c. 

Saturated  aqueous  solution  of  orange-G 70    " 

Saturated  aqueous  solution  of  methyl-green 80    " 

Aquse  dest 150    " 

Abs.  alcohol ' 80    " 

Glycerin 20    " 

The  granules  in  question  occur  as  separate  bodies  or  as  groups, 
lying  in  the  protoplasm  immediately  around  the  nucleus.  They  are 
met  with  in  the  mononuclear  forms  in  particular,  and,  according  to 
Neusser,  are  composed  of  some  derivative  of  the  nucleo-albumin  and 
indicative  of  increased  uric  acid  formation.  The  granules  occur  in 
gout,  and  also  in  certain  cases  of  myelogenous  leukaemia,  tuberculosis, 
diabetes,  and  other  diseases.  They  are  insignificant  of  a  uric  acid 
diathesis  "in  the  clinical  sense."  In  discussing  Neusser' s  paper 
Lonit  called  attention  to  the  fact  that  similar  granules  occur  in  the 
leucocytes  of  the  bone-marrow  of  rabbits. 

Other  observers  have  found  these  granules  in  a  variety  of  condi- 
tions and  incline  to  regard  them  of  less  significance  than  Neusser  is 
disposed  to  admit. 

Poikilocytosis.  This  is  a  condition  in  which  the  red  blood-cells  are 
very  irregular  in  shape — oval,  pointed,  angular,  or  reniform.  It  is  a 
common  accompaniment  of  severe  anaemia,  particularly  leucocythaemia 
and  idiopathic  anaemia.      (Plate  IX.) 

Microcythcemia.  This  is  a  condition  of  the  blood  characterized  by 
the  presence  of  cells  containing  haemoglobin,  but  the  cells  are  much 
smaller  than  an  ordinary  red  corpuscle.  They  arc  found  in  anaemias 
and  toxaemias.      (Plate  VIII.) 

Melanosmia.  Melanaemia  is  a  rare  condition  in  which  black,  brown, 
or  yellow  granules  are  seen  floating,  either  free  among  the  blood-cells, 


'734  SPECIAL  DIAGNOSIS. 

or,  more  commonly,  enclosed  in  cells  resembling  leucocytes.  They  are 
present  in  malarial  fevers,  particularly  the  chronic  forms,  and  in 
relapsing  fever. 

Lipcemia  is  the  presence  in  the  blood  of  fat,  usually  in  the  form  of 
small  droplets,  easily  detected  by  the  microscope.  The  diagnosis  can 
be  confirmed  by  treating  the  fresh  preparation  with  a  1  per  cent,  solu- 
tion of  osmic  acid,  followed  by  a  weak  aqueous  solution  of  eosin.  The 
fat- drops  will  appear  black  among  the  faintly  stained  acid  corpuscles. 
Lipsemia  occurs  in  the  course  of  chronic  alcoholism,  chronic  nephritis, 
and  diabetes,  and  after  injuries  to  the  bone-marrow. 

The  Acidity  of  Blood.  The  total  acidity  of  the  blood  is  best  de- 
termined by  Landois'  titration-method  as  follows:  Prepare  a  decinormal 
solution  of  tartaric  acid  by  dissolving  7.5  grammes  of  the  chemically 
pure  salt  in  1  litre  of  distilled  water.  By  diluting  centinormal  and 
millinormal  solutions  are  obtained.  Prepare  a  series  of  solutions  as 
follows  : 

I.  contains  0.9  c.c.  centinormal  solution  tartaric  acid  -(-0.1  c.c.  sat- 
urated potassium  sulphate  solution. 

II.  contains  0.8  c.c.  centinormal  solution  tartaric  acid  +  0.2  c.c. 
sulphate  solution. 

IX.  contains  0.1  centinormal  acid  +  0.9  c.c.  sulphate  solution. 

X.  contains  0.9  c.c.  millinormal  acid  +  0.1  c.c.  sulphate  solution. 
XVIII.  contains  0.1  c.c.  millinormal  acid  +  0.9  c.c.  sulphate  solu- 
tion. 

In  each  of  a  series  of  watch-glasses  mix  1  c.c.  fluid  (each  watch- 
glass  containing  a  different  strength,  as  in  the  series  above  given)  with 
0.1  c.c.  of  blood.  This  can  be  done  by  a  graduated  pipette.  The 
pipette  of  a  Thoma-Zeiss  haernocytometer  answers  very  well. 

Test  the  contents  of  each  watch-glass  with  a  strip  of  delicate  litmus- 
paper,  and  note  in  which  solution  the  reaction  is  neutral.  This  opera- 
tion must  be  done  quickly,  the  whole  process  not  taking  more  than  one 
and  a  half  minutes  (V.  Jaksch). 

Suppose  0.4  c.c.  tartaric  acid  neutralizes  1  c.c.  of  blood;  now  0.4  c.c. 
tartaric  acid  neutralizes  0.0016  gramme  caustic  soda.  Therefore  0.1 
c.c.  blood  =  0.0016  sodic  hydrate,  and  1  c.c.  =0.16.  The  normal 
alkalinity  is  1  part  XaOH  to  26  to  30  parts  of  blood,  or  1  c.c.  blood 
=  0.33  to  0.38  gramme  NaOH. 

The  alkalinity  of  the  blood  is  diminished  in: 

1.  Fevers  and  cachexias. 

2.  Toxic  conditions,  as  uraemia,  diabetes,  and  jaundice.  Or  certain 
poisons,  as  C02  and  phosphorus. 

3.  Pernicious  anaemia,  simple  anaemia,  and  leukaemia. 

4.  Chronic  articular  rheumatism  and  gout  (not  in  acute  articular 
rheumatism).    This  may,  perhaps,  be  due  to  the  accompanying  anaemia. 

It  is  increased,  perhaps,  in  chlorosis,  though  this  is  doubted  by  some 
authorities. 

The  Specific  Gravity.  The  specific  gravity  of  the  blood  is  best 
determined  by  the  following  method: 

Prepare  a  series  of  solutions  of  water  and  glycerin  in  such  propor- 
tion that  they  form  a  series  gradually  ascending  in  specific  gravity  from 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       735 

1040  to  1080.  Place  from  80  to  100  c.c.  of  each  solution  in  a  series  of 
small  glass  jars  and  bring  a  drop  of  blood  exactly  in  the  middle  of  each, 
as  follows  :  A  hypodermic  syringe  is  connected  by  a  small  rubber  tube 
with  a  right-angled  glass  capillary  tube.  A  drop  of  blood  is  obtained 
from  the  finger  in  the  usual  manner,  and  is  drawn  by  means  of  the 
syringe  into  the  capillary  tube.  By  a  gentle  motion  of  the  syringe  a 
small  drop  is  expelled  into  the  fluid  from  the  point  of  the  tube.  The 
drop  will  remain  stationary  if  the  specific  gravity  of  the  fluid  equals 
that  of  the  blood;  will  sink  if  the  fluid  be  of  less  specific  gravity  than 
that  of  the  blood,  or  will  rise  if  the  fluid  be  of  greater  specific  gravity 
than  the  blood.  By  repeated  examination  the  specific  gravity  of  any 
specimen  can  be  easily  determined.  The  glycerin  mixture  can  be 
preserved  by  the  addition  of  a  small  amount  of  thymol  and  may  be 
used  a  second  time,  but  in  this  case  it  is  necessary  to  redetermine  its 
specific  gravity  before  each  using. 

The  specific  gravity  of  the  blood  is  normally  less  in  women,  and  is 
diminished  in  severe  symptomatic  anaemias,  pernicious  anaemia,  chlo- 
rosis, leukaemia,  and,  according  to  Monti  (Arch.  f.  Kinder heilk.,  Bd. 
xviii.  S.  161),  in  nephritis.  It  is  increased  in  infancy  and  acute 
febrile  diseases,  as  pneumonia,  pleurisy,  etc.  (Monti,  ibid.),  and  also 
in  diphtheria  (Fibrenthal  and  Bernhard,  ibid.,  Bd.  xvii.  H.  5  u.  6). 

Parasites  in  the  Blood  The  principal  vegetable  parasites  are  : 
(1)  Spirilla  of  relapsing  fever;  (2)  tubercle-bacilli;  (3)  anthrax-bacilli; 
(4)  bacilli  of  glanders;  (5)  typhoid  bacilli;  (6)  streptococci  and  staphy- 
lococci. 

The  animal  parasites  are  :  (1)  Filaria  sanguinis  hominis;  (2)  distoma 
haematobium;  (3)  plasmodium  of  malaria. 

The  Spirilla  of  Relapsing  Fever.  These  are  slender,  thread- 
like organisms  of  spiral  shape,  seven  or  eight  times  the  length  of  a 
red  blood-cell,  with  a  very  lively  forward  movement  in  the  direction 
of  the  long  axis.  Under  a  low  power  the  blood  may  appear  to  be  in 
motion,  as  the  result  of  their  movement.  They  have  so  far  been  found 
only  in  the  height  of  the  febrile  attacks;  but  Von  Jaksch  states  that 
as  long  as  a  relapse  is  to  be  feared  the  blood  contains  peculiar,  highly 
refracting  bodies  resembling  diplococci,  which  are  especially  numerous 
before  the  attack;  in  some  cases  it  has  seemed  to  him  that  these  diplo- 
cocci at  the  very  beginning  of  an  attack  develop  into  short,  thick  rods, 
from  which  the  spirilla  develop;  they  may,  therefore,  prove  to  be  spores. 
Staining  is  unnecessary  for  the  detection  of  spirilla,  but  cover-glass 
preparations  of  the  blood  can,  if  desired,  be  stained  with  fuchsin  or 
gentian-violet.      (Plate  II.,  Fig.  4,  A.) 

Tubercle-bacilli.  Tubercle-bacilli  have  been  found  in  the 
blood  in  miliary  tuberculosis.  Cover-glass  preparations  of  the  blood 
are  made  and  stained  as  in  the  case  of  sputum  (q.  v.). 

Plasmodia  of  Malaria.  The  plasmodia  of  malaria  were  first 
pointed  out  by  Lavcran.  They  have  been  studied  in  Italy,  especially 
by  Marchiafava  and  Golgi,  and  in  this  country  by  Councilman,  Osier, 
and  Dock.  Minute  amoeboid  bodies  are  found  in  the  red  corpuscles. 
These  become  pigmented  with  altered  haemoglobin,  and  grow  until  they 


736 


SPECIAL  DIAGNOSIS. 


fill  nearly  the  whole  of  the  cell,  the  pigment  being  arranged  chiefly  in  a 
peripheral  ring.  Later,  the  amoeboid  bodies  become  spherical  and  trans- 
parent, the  pigment  collecting  in  the  centre.  Sporulation  now  begins 
and  a  fresh  crop  of  small,  rounded  parasites  appears,  to  begin  the  same 
cycle  over  again  in  fresh  corpuscles.     (Plate  XL,  Fig.  2.) 

Three  forms  of  parasites  are  described  :  1.  The  tertian,  which  sporu- 
lafce  at  the  end  of  four  hours,  begin  as  small  amoeboid  intracorpuscular 
bodies,  gradually  enlarge,  produce  fine  brownish  pigment-granules,, 
and  finally  completely  fill  the  corpuscle.  In  sporulation  the  segments 
number  fifteen  to  twenty. 

2.  The  quartan,  which  sporulate  at  intervals  of  seventy-two  hours, 
are  smaller,  amoeboid  movement  is  not  so  marked;  when  full  grown 
the  parasites  are  smaller,  and  the  corpuscle  tends  to  shrink  about  them 
and  to  become  a  deeper  greenish  color.  They  sporulate  with  five  to 
ten  segments  in  a  very  beautiful  characteristic  roseate  appearance. 

3.  The  sestivo-autumnal  are  smaller,  and  contain  less  pigment.  The 
period  of  sporulation  is  still  in  dispute.  They  usually  form  ovoid- 
crescentic  or  round  bodies  with  coarse  pigment-granules  in  the  centre. 


Fig.  144. 


Malarial  plasmodia.  (Reproduced  from  colored  plate.)  To  the  right  two  normal  red  blood-cells 
with  central  depression.  In  addition,  several  others  with  bluish  contained  bodies  and  pigment- 
sprinkled  cells,  which  show  the  endogenous  development  of  the  plasmodia.  Besides,  two  of 
Laveran's  bodies,  one  exhibiting  a  delicate  little  basket  appearance.  Near  the  centre  a  poly- 
nuclear  white  cell  with  bluish  nuclei  and  red  granulation.    (H.  Rieder.) 

Golgi  maintains  that  in  tertian  malarial  fever  the  period  between 
invasion  of  the  corpuscles  and  the  sporulation  is  two  days;  in  quartan, 
three  days,  the  difference  in  cycle  being  due  to  a  difference  in  the 
parasites. 

The  onset  of  the  fever  corresponds  in  time  to  the  division  of  the 

parasites. 

The  crescentic  form  described  by  Laveran  is  said  to  be  more  com- 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       737 

mon  in  the  irregular  forms  of  malarial  fever.  Canalis1  says  that  it 
only  makes  its  appearance  several  clays  after  the  first  access  of  fever. 
It  is  somewhat  longer  than  a  red  blood-cell,  and  the  pigment  tends  to 
collect  in  a  focus  about  the  middle  of  the  parasite.  Subsequently  it 
becomes  oval  and  divides  into  eight  or  more  daughter-cells. 

Another  form  with  flagella  is  occasionally  found.  Councilman  says 
it  is  most  common  in  blood  drawn  directly  from  the  spleen. 

The  plasmodinm  of  malaria  may  be  stained  as  follows  :  Cover-glass 
preparations  of  the  blood  spread  very  thinly  are  dried  in  the  air  and 
fixed  by  immersion  for  twenty  minutes  or  half  an  hour  in  a  mixture  of 
equal  parts  of  alcohol  and  ether.  They  are  then  stained  for  twenty  to 
thirty  minutes  in  concentrated  aqueous  solution  methylene-blue,  60 
parts ;  J  per  cent,  solution  eosin  in  75  per  cent,  alcohol,  20  parts;  dis- 
tilled water,  40  parts;  20  per  cent,  solution  potassium  hydroxide,  12 
drops.  The  cover-glasses  are  then  washed  in  water,  dried,  and  are 
then  ready  for  mounting.  The  red  blood-cells  are  stained  rose,  the 
nuclei  of  leucocytes  a  deep  dark-blue,  and  any  plasmodia  a  delicate 
sky-blue.     (See  Malarial  Fever.) 

Anthrax-bacilli.  Anthrax-bacilli  are  found  in  small  numbers 
in  human  beings  suffering  from  anthrax,  especially  in  blood  from  the 
spleen.  They  are  from  5  to  12//.  long  and  1//  broad,  immovable  rods, 
appearing  as  though  divided  into  sections.  They  can  be  seen  without 
staining,  bat  the  bacilli  readily  take  the  basic  aniline  dyes.  (Plate  II., 
Fig.  2,  a,  and  Plate  XL,  Fig.  1.) 

Bacilli  of  Glanders.  These  are  occasionally  found  in  human 
blood.  They  consist  of  rods  2  to  3//  long  and  0.3  to  0.4//  broad,  fre- 
quently having  spores  on  the  ends.  Loffler'  s  staining-method  is  recom- 
mended for  their  detection. 

Fig.  145. 


Filaria  alive  in  the  blood.    Instantaneous  photomicrograph.    Four  hundred  diameters  j^TF 
magnification.    Four  millimetres  Zeiss  apochromatic.    (F.  P.  Henry.) 

The  Filaria  Sanguinis  Hominis.  Filarise  are  found  in.  the 
blood  and  lymph  of  persons  who  live  in  the  tropics,  and  in  a  few 
instances  have  been  found  in  native  Americans  (John  Guiteras). 
They  have  a  blunt,  rounded  head  with  a  tongue-like  process  and  a  long, 
pointed  tail.  They  produce  lymphatic  swellings  (particularly  of  the 
scrotum),  chyluria,  and  hematuria. 

Patrick  Manson2  says  the  following  are  the  commonest  mistakes  in 


1  Fortschritte  der  Medicin,  1890,  viii.  Nos.  8  and  0. 

2  Trans.  Seventh  International  Congress  of  Hygiene  and  Demography,  vol.  i.  p.  93. 

47 


738  SPECIAL  DIAGNOSIS. 

the  search  for  filariae:  (1)  The  use  of  too  high  a  niagnifying-power ; 
(2)  employing  too  strong  illumination;  (3)  searching  unmethodically, 
and  in  too  small  a  quantity  of  blood;  and  (4)  looking  for  filarise  in 
blood  drawn  from  the  body  at  a  time  when  the  particular  species  sought 
for  is  normally  absent  from  the  circulation.  He  describes  three  forms  : 
filaria  sanguinis  hominis  nocturna  (the  ordinary  form) ;  filaria  sanguinis 
hominis  diurna  ;  and  perstans.  The  last  appears  to  be  the  one  associated 
with  the  production  of  the  disease  known  on  the  west  coast  of  Africa 
as  "  sleeping  sickness."  He  prefers  dry  preparations  of  the  blood, 
stained  with  a  ^  per  cent,  eosin  solution  or  a  weak  solution  of  fuchsin 
(one  drop  of  the  saturated  alcoholic  solution  to  an  ounce  of  water). 
If  a  thin  film  of  blood,  before  it  has  fully  dried,  be  held  over  acetic 
acid  so  as  to  imbibe  the  fumes,  and  be  then  stained  in  a  J  per  cent, 
solution  of  eosin,  the  blood  is  stained,  but  any  filaria?  remain  pearly 
white. 

Aneemia. 

Anaemia  is  a  condition  characterized  by  a  reduction  in  the  number 
of  red  blood-cells,  or  of  their  haemoglobin,  or  of  the  albumin,  or  of 
all  combined. 

For  clinical  purposes  it  is  necessary  to  make  a  number  of  divisions 
of  anaemia,  though  on  aetiological  and  pathological  grounds  a  number 
of  them  will  no  doubt  soon  be  grouped  together. 

The  following  classification  of  anaemias  is  helpful  in  the  study  of 
anaemia.  In  it  both  pernicious  anaemia  and  chlorosis  are  regarded  as 
hsemolytic  in  origin,  the  destructive  agent  probably  being  absorbed 
from  the  intestine. 

f  Pernicious  anaemia. 
,  „        ,_„  Other  toxic  anaemias. 

fHaemolytic,        j  Cnlorosis. 

I.  Parasitic  anaemia  (some  forms). 


f  Xon-cytogenic, 


f  Parasitic  anaemia  (some  forms). 

.        Post-hemorrhagic  anaemia. 
Oligocvthaemic,  i    .  .    .        ,         „  „•„,„.„ 

°     •  Anaemia  from  loss  of  albumin. 

L  Anaemia  of  malnutrition. 

-  Spleno-myelogenic. 
Leucocytic,  Leucocythaemia,  -i  Lymphatic. 


•f 

[  Cytogemc,  (-Medullary  or  myelogenic. 

[  Xon- leucocytic,      Hodgkin's  disease (?). 

I.  Toxic  Anaemias.  Anaemia  may  be  toxic  in  origin,  the  poison 
being  either  developed  in  the  body  or  introduced  from  without.  Tox- 
aemia is,  sometimes  at  least,  a  factor  in  the  anaemias  which  develop  in 
the  course  of  acute  infectious  diseases  or  during  convalescence  from 
them;  according  to  Hunter,  pernicious  anaemia  would  be  classed  under 
this  head.  The  metallic  poisons,  particularly  lead,  mercury,  arsenic, 
phosphorus,  the  potassium  salts,  especially  the  chlorate;  certain  of  the 
antipyretics,  notably  pyrodin;  and  the  aniline-preparations  are  capable 
of  producing  anaemia. 

II.  Parasitic  Axjemias.  Anaemia  may  be  parasitic.  1.  To  this 
class  belongs  the  anaemia  of  malaria,  which  is  believed  to  be  due  to  the 
Plasmodium  malarice  described  by  Laveran. 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       739 

2.  Certain  intestinal  worms  are  found  associated  with  marked  anae- 
mias, (a)  The  bothriocephalus  latus  sometimes  produces  a  disease 
closely  resembling  pernicious  ansemia,  but  whether  by  direct  destruc- 
tion of  the  blood,  or  by  the  development  of  toxic  products  themselves 
destructive,  is  uncertain;  it  may  be  present  in  large  numbers  without 
giving  rise  to  anaemia. 

Fig.  146. 


Severe  ansemia.  (Reproduced  from  colored  plate.)  Dry  preparation.  Stained  with  eosin 
methyl-blue.  X  300.  Great  poikilocytosis  of  red  cells.  Many  macrocytes  and  microcytes.  To 
the  left  above,  a  mononuclear  leucocyte. 

(6)  The  ankylostomum  duodenale  is  believed  to  be  the  cause  of  the 
ansemia  known  variously  as  Egyptian  or  African  chlorosis,  tropical 
anaemia,  brick-burner's  ansemia,  etc. 

(c)  The  anguillula  intestinalis  is  the  cause  of  "  Cochin-China  diar- 
rhoea "  and  its  associated  ansemia. 

3.  The  fit 'aria  sanguinis  hominis  may  produce  ansemia  by  blocking 
up  the  lymph-channels. 

4.  The  Bilharzia  hoematobia  may  produce  ansemia  by  inducing 
hsematuria. 

III.  Anemia  from  Hemorrhage.  Ansemia  may  be  due  to 
hemorrhage.  In  addition  to  accidental  and  post-partum  causes,  pur- 
pura, haemophilia,  monorrhagia,  and  metrorrhagia  are  frequent  Causes. 

IV.  An.emia  from  Constitutional  and  Local  Diseases. 
Ansemia  is  often  a  marked  symptom  of  constitutional  and  local  dis- 
eases, such  as  tuberculosis,  syphilis,  cancer,  rheumatism,  scrofula, 
scurvy,  rickets,  Bright' s  disease,  chronic  catarrhal  gastritis,  and  others. 
The  amemia  here  may  be  due  to  the  malnutrition  and  interference  with 
digestion  brought  about  by  the  disease,  or,  as  in  the  case  of  Blight's 
disease,  in  part  to  the  direct  loss  of  albumin,  and  in  dyspeptic  condi- 
tions to  inability  to  take  and  assimilate  food. 

In  many  cases  of  simple  symptomatic  "anaemia  the  spleen  may  become 
progressively  enlarged,  probably  secondarily.    In  other  eases  there  is  an 


740  SPECIAL  DIAGNOSIS. 

enlargement  of  the  spleen  in  Hodgkin's  disease.     In  no  case  is  there 
a  primary  splenic  anaemia. 

Y.  Anemia  of  Malnutrition.  Anaemia  may  also  be  the  result 
of  malnutrition  from  deficient  or  improper  food,  or  from  the  poisonous 
influences  of  unsanitary  surroundings. 

Chlorosis.  Chlorosis  is  a  form  of  anaemia  occurring  especially  in 
young  girls  about  the  period  of  puberty,  and  characterized  by  great 
pallor  of  the  skin  and  mucous  membranes,  with  a  greenish  tint  of  the 
skin,  a  pearly  eye,  languor,  weariness,  suppression  or  irregularity  of 
menstruation,  venous  hum  in  the  vessels,  dyspnoea,  palpitation,  dizzi- 
ness, neuralgias,  and  an  unstable  condition  of  the  nervous  system. 
In  spite  of  the  extreme  pallor  there  is  usually  but  little  loss  of 
flesh.  The  skin  may  be  pigmented,  especially  around  joints.  The 
bowels  are  usually  constipated;  the  urine  abundant,  pale,  and  of  low 
specific  gravity.  The  digestion  is  disturbed,  the  appetite  capricious, 
and  the  patients  sometimes  crave  unwholesome  things,  such  as  earth, 
slate-pencils,  vinegar,  and  the  like.  A  systolic  murmur  over  the  base 
of  the  heart  is  common.  Gastralgia  is  more  common  than  in  other 
forms  of  anaemia. 

The  changes  in  the  blood  are  very  important.  There  is  always  a 
marked  reduction  in  the  haemoglobin,  the  percentage  falling  sometimes 
to  30  or  25  per  cent,  of  the  normal.  The  red  blood-cells  are  usually 
also  reduced,  but  not  in  the  same  proportion  as  the  haemoglobin.  For 
example,  there  may  be  4,000,000  red  cells,  but  only  30  per  cent,  of 
haemoglobin.  Sometimes  there  is  no  diminution  in  the  number  of  red 
cells;  the  latter,  however,  appear  pale,  vary  considerably  in  size,  micro- 
cytes  and  occasionally  poikilocytes  are  present,  and,  in  severe  cases, 
nucleated  red  corpuscles  are  found;  occasionally  macrocytes  occur,  but 
in  general  the  size  of  the  red  cells  is  below  that  which  is  usually  found. 
Superacidity  of  gastric  juice  is  commonly  present.  The  number  of 
leucocytes  varies  but  little  from  the  normal,  but  there  may  be  a  slight 
increase.  Occasionally  there  is  a  rise  of  temperature,  but  it  is  prob- 
ably due  to  some  complication.     (Plate  VIII.,  Fig.  1.) 

The  cause  of  chlorosis  has  not  been  determined  satisfactorily.  Vir- 
chow  has  established  the  existence  Of  congenital  narrowing  of  the 
bloodvessels.  Sir  Andrew  Clark  thinks  it  is  due  to  the  absorption  of 
poisonous  matter  from  the  intestine;  the  great  benefit  that  follows  saline 
purgatives  in  many  cases  indicates  that  faecal  toxaemia  is  a  factor  in 
these  cases.    .  Forchheimer1  also  looks  upon  it  as  intestinal  in  origin. 

Sex  and  puberty  are  predisposing  causes;  but  chlorosis  may  occur 
in  boys,  and  appear  in  girls  before  puberty,  and  in  young  women  con- 
siderably after  that  period.  The  prognosis  is  favorable;  it  may,  how- 
ever, be  complicated  with  gastric  ulcer,  chorea,  tuberculosis,  and 
endocarditis.     Recovery  is  often  slow  and  interrupted  by  relapses. 

Idiopathic  Anaemia.  Idiopathic,  or  pernicious,  anaemia  is  a  form 
in  which  the  diminution  of  red  blood -cells  reaches  an  extreme  degree. 

1  Trans.  Assoc.  Amer.  Phys.,  1893. 


PLATE    VIII. 
FIG.  i. 

0 


J3L-  0^2  o 


£  00 

0  6*^0  O    °  £o        °  ^ 

■  ft°    0  o 
o0 

Blood  from  Case  of  Chlorosis,  showing  slight  Staining  of  the  Red  Blood-corpuscles, 

and  presence  of  Mononuclear  Leucocytes. 

(Oc.  4,  ob.  Via  immersion  )    Drawn  bv  J.  D.  Z.  Chase. 


FIG.  2. 


o 


o 


Blood  in  Pernicious  Anaemia,  showing  Macrocytes  and  Microcytes. 
i  lvisiu  stain,  oc.  I,  ob.  '/is  oil  immersion  i    Drawn  by  J.  D.  /..  <  lhase 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       741 

It  occurs  without  adequate  known  cause,  and  runs  a  progressive  course 
with  remissions;  it  usually  terminates  in  death. 

The  disease  usually  develops  slowly  and  insidiously,  the  patient  pre- 
senting the  ordinary  symptoms  of  anosmia — pallor,  weakness,  shortness 
of  breath,  palpitation,  venous  murmurs,  loss  of  appetite,  and  impaired 
digestion.  As  the  disease  progresses  the  skin  becomes  of  a  pale  lemon 
hue,  weakness  and  dyspnoea  increase,  the  patient  has  attacks  of  dizzi- 
ness, faintness,  and  ringing  in  the  ears;  there  may  be  slight  oedema, 
and  hemorrhages  from  the  nose,  the  bowels,  and  into  the  retina  occur. 
The  hemorrhages  are  small  and  distinct  in  the  skin  and  mucous  mem- 
branes. The  urine  is  of  low  specific  gravity,  and  usually  contains  an 
increased  amount  of  uric  acid.  According  to  Hunter,  the  urine  should 
be  dark  and  contain  a  pathological  amount  of  urobilin,  some  renal 
epithelium,  a  few  casts  containing  blood-pigment,  and  an  increased 
amount  of  iron.     The  bowels  may  be  disturbed  by  diarrhoea. 

A  peculiarity  of  the  disease  is  the  occurrence  of  fever  of  an  irreg- 
ular type.  The  temperature  rarely  rises  higher  than  102°  or  103°  in 
the  evenings  and  is  followed  by  a  morning  remission.  It  is  not  usually 
present  in  the  early  stages  of  disease,  may  be  absent  for  weeks  at  a 
time  when  the  disease  is  fully  developed,  and  may  cease  entirely  in  the 
later  stages. 

In  spite  of  extreme  exhaustion,  anaemia,  and  widespread  functional 
disturbance,  there  is  no  emaciation  ;  the  patient  appears  well  nourished. 

The  blood  appears  pale  and  watery  to  the  naked  eye ;  there  is  diffi- 
culty in  obtaining  by  puncture  a  sufficiently  large  drop  for  examina- 
tion. The  specific  gravity  is  lowered,  often  being  1028  instead  of  1055. 
It  has  been  found  deficieut  in  fibrin,  iron,  and  nitrogen. 

The  blood-changes  in  idiopathic  anaemia  are  characteristic,  and  are 
essential  to  the  diagnosis  of  the  disease.  In  brief,  they  are  :  (1)  very 
great  reduction  in  the  number  of  red  blood-cells ;  (2)  an  absolute 
diminution  in  the  amount  of  haemoglobin,  but  as  compared  with  the 
number  of  red  cells  there  may  be  a  proportionate  increase ;  (3)  consid- 
erable variation  in  the  size  of  the  cells,  the  average  size  of  the  cells 
probably  being  larger;  (4)  poikilocytosis;  (5)  nucleated  red  blood-cells; 
(6)  degenerative  cells.     (Plate  VIII.,  Fig.  2.) 

Reduction  in  the  number  of  red  blood-cells  (oligocythemia)  reaches 
a  more  extreme  degree  in  pernicious  anaemia  than  in  any  other  disease; 
the  number  often  falls  below  1,000,000,  and  in  one  case  reported  by 
Quincke1  the  number  was  only  143,000  per  cubic  millimetre.  The 
shape  of  many  of  the  cells  is  altered;  they  are  oval,  elongated,  bent, 
or  have  projections  of  their  substance  (poikilocytosis).  The  size  of 
the  cells  varies;  there  are  microcytes  and  megaloblasts;  but  the  occur- 
rence of  a  distinct  proportion  of  large  nucleated  red  blood-cells  (megalo- 
blasts) is  regarded  by  Ehrlich  as  almost  diagnostic.  The  average  size  of 
the  red  cell  seems  to  be  increased,  and  so  is  the  proportionate  amount 
of  haemoglobin  in  each  cell.  The  latter  is  a  very  characteristic  symp- 
tom (the  only  one,  according  to  Hunter).  There  arc  also  red  corpus- 
cles   which  arc   stained  by   mcthylene-blue;     these   arc    regarded    as 

1  Deut.  Arch.  fiir.  klin.  Med.,  Bd.  xx. 


742  SPECIAL  DIAGNOSIS. 

degenerative  by  Ehrlich.  The  leucocytes  are  "  usually  diminished 
in  number,  showing  a  relative  increase  in  the  small  mononuclear  ele- 
ments (lymphocytes,  small  transparent  forms),  while  the  multinuclear 
elements  are  relatively  diminished,  sometimes  being  under  50  per 
cent."1 

The  blood-condition  is  not  constant,  but  is  subject  to  wide  variations. 
Von  JNToorden  has  recently  found  that  in  a  very  short  time  a  change 
in  the  form  of  the  blood,  a  "  formal"  crisis,  may  occur.  A  "formal" 
overflow  of  the  blood  with  polynuclear  leucocytes  and  nucleated  red 
blood-cells  takes  place  before  a  period  of  improvement.  Whereas, 
before  a  period  in  which  the  blood  becomes  worse  and  before  the  final 
stage,  the  blood  becomes  poor  in  leucocytes  and  nucleated  red  blood- 
cells.2 

The  aetiology  of  the  disease  has  not  been  determined  satisfactorily. 
It  is  more  common  in  Germany  and  Switzerland  than  in  other  parts 
of  Europe  or  in  America.  It  occurs  most  frequently  after  the  twen- 
tieth year,  and  between  that  and  the  age  of  fifty.  Excluding  the  influ- 
ence of  pregnancy  and  parturition,  sex  makes  no  difference.  Previous 
exhausting  disease,  chronic  gastric  and  intestinal  catarrh,  great  phys- 
ical overexertion,  exposure,  great  shock  or  fright,  precede  in  certain 
cases  the  development  of  the  disease.  It  is  probably  due  to  faulty 
haematogenesis  and  haemolysis.  (Henry,  University  Medical  Magazine, 
February,  1893;  Stengel,  Therapeutic  Qaz.,  June,  1894.) 

Petrone  and  Halst  regard  the  disease  as  infectious  and  its  germ  iden- 
tical with  that  found  by  Frankenhauser.  Von  Jaksch  supposes  that 
it  is  brought  about  by  a  living  contagium.  Hunter  traces  the  cause 
to  a  poison  produced  by  bacteria  in  the  gastro-intestinal  canal.  The 
cases  of  Gibson,3  in  which  cure  or  great  improvement  followed  the  use 
of  beta-naphthol,  tend  to  support  Hunter's  view. 

The  usual  post-mortem  lesions  are  fatty  degeneration  of  the  heart 
and  liver,  red  and  lymphoid  bone-marrow,  and  deposits  of  iron  in  the 
liver,  usually  in  the  perijmeral  and  middle  zones  of  the  lobules 
(Hunter).  Hemorrhages  into  the  skin,  serous  membranes,  and  retina 
are  found.  The  muscles  are  often  of  a  deep  red  and  the  fat  through- 
out the  body  of  a  light  yellow  color.  Degeneration  of  the  posterior 
columns  and  pyramidal  tracts  of  the  cord  may  occur.  (Burr,  Univer- 
sity Medical  Magazine,  April,  1895.) 

Diagnosis.  The  most  important  diagnostic  features  of  the  disease 
are  extreme  oligocythaemia,  relatively  high  percentage  of  haemoglobin, 
great  poikilocytosis,  which  may,  however,  occur  in  any  severe  anaemia, 
a  noticeable  number  of  large  nucleated  red  blood-  cells  (gigantoblasts), 
and  average  increase  in  the  size  of  the  cells,  and  all  this  without  emaci- 
ation or  discoverable  local  disease  which  can  bear  a  causative  relation 
to  the  anaemia.  In  addition  retinal,  subcutaneous,  and  submucous 
hemorrhages,  a  urine  with  high  specific  gravity,  high  color,  with  uro- 
bilin in  excess,  alternating  with  urine  of  low  specific  gravity,  in  the 
absence  of  organic  disease,  point  to  idiopathic  or  pernicious  anaemia. 

1  W.  S.  Thayer :  Boston  Med.  and  Surg.  Journal,  February  16  and  23, 1893. 

2  Quoted  bv  Weiss,  Diagnostisches  Lexikon. 

3  Edinburgh  Medical  Journal,  Oct.(?)  1892. 


PLATE    IX. 


Fig.  i. 


O      °o 


°0 


~£> 


Blood  from  Case  of  Secondary  Anaemia. 

1    Poikilocytes.  3.  Lymphocytes. 

2.  Macrocytes.  4.  Nucleated  red  blood-corpuscle. 

5  and  6.  Polynuclear  leucocytes. 

(Oc.  4,  ob.  Via  immersion.)    Drawn  by  J.  D.  Z.  Chase. 


Fig.  2. 


CO 
W0 


$• 


&C 


Leukasmic  Blood. 


i    Polynuclear  leucocj  tes. 

■_'.  l-j  isinoph  ill'  cell  I  mononuclear). 


:;.  Large  mononuclear  leucocyte 
I.  Small  Lymphocyte. 

(Oc.  I,  ob.  '  is  immersion.)    Drawn  by  J.  I>.  z.  Chase. 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       743 

Leucocythaemia.  Leucocythaeniia,  or  leukaemia,  is  a  chronic  dis- 
ease of  the  blood-making  organs  characterized  by  great  and  persistent 
increase  in  the  Avhite  blood -corpuscles;  by  a  diminished  number  of  red 
blood-cells,  which  are  altered  in  shape  and  size,  and  display  nucleated 
and  degenerate  forms;  by  a  lessened  amount  of  haemoglobin,  and 
by  enlargement  of  the  spleen,  lymphatic  glands,  or  medulla  of  bone. 
The  disease  occurs  twice  as  frequently  in  men  as  in  women,  and  two- 
thirds  of  the  cases  appear  between  the  twentieth  and  fiftieth  years. 
In  women  pregnaucy,  parturition,  and  the  cessation  of  menstruation 
are  causative  factors,  while  in  both  sexes  depressing  influences  upon 
body  or  mind,  and  antecedent  disease,  particularly  malarial  fever,  have 
a  distinct  influence. 

The  first  symptom  noted  is  generally  enlargement  of  the  abdomen; 
subsequently  the  patient  complains  of  pains  in  the  splenic  region,  weak- 
ness, dyspnoea,  hemorrhage,  oedema,  and  digestive  derangements.  Occa- 
sionally profuse  hemorrhage  from  trifling  cause,  as  the  drawing  of  a 
tooth,  has  been  the  earliest  symptom  noted.  The  increase  of  white 
cells  and  diminution  of  red  cells  is  progressive,  and  soon  makes  itself 
evident  in  the  pallor  of  the  skin  and  mucous  membranes,  and  in 
increasing  weakness  and  dyspnoea. 

In  the  sjjleno-medullary  form  of  the  disease  the  spleen  steadily  en- 
larges, but  may  attain  considerable  size  before  the  patient  becomes  aware 
of  it.  The  enlargement  is  not  usually  painful,  but  gives  rise  to  a  feel- 
ing of  distention,  weight,  and  dragging.  There  may  be  tenderness  on 
palpation  and  pressure,  and  sometimes  the  patient  complains  of  sharp, 
stabbing  pains,  due  either  to  attacks  of  local  peritonitis  or  to  sudden 
enlargement  of  the  spleen  and  consequent  stretching  of  the  capsule. 
The  splenic  enlargement  is  uniform,  so  that  its  shape  and  characteristic 
notch  are  unchanged.  Moreover,  the  spleen  remains  in  contact  with 
the  abdominal  walls,  lying  in  front  of  the  splenic  flexure  of  the  colon, 
pushing  aside  the  descending  colon  and  small  intestine,  moving  with, 
respiration,  and  presenting  the  usual  physical  signs  of  a  solid  organ. 
Not  infrequently  the  enlargement  is  so  great  as  to  fill  the  left  hypo- 
chondriac and  iliac  regions,  and  reach  beyond  the  middle  line  toward 
the  right  groin.  Sometimes  a  venous  hum  can  be  heard  over  it.  Pallor, 
however,  is  not  a  constant  symptom;  more  frequently  the  cheeks  are 
flushed  and  the  lips  red. 

As  the  result  of  this  enlargement  the  diaphragm  is  pushed  upward, 
increasing  the  dyspnoea  already  caused  by  anaemia,  and  sometimes 
inducing  palpitation.  The  gastric  functions  are  disturbed  from  pres- 
sure; vomiting  and  other  symptoms  of  dyspepsia  are  common. 

A  rise  in  temperature  is  a  very  common  symptom.  The  fever. is  of 
irregular  type,  usually  with  nocturnal  exacerbations,  the  temperature 
not  often  rising  above  102°.  The  febrile  type  may  be  intermittent  or 
remittent,  and  sometimes  there  are  periods  of  apyrexia. 

The  pyrexia  is  said  to  be  most  marked  toward  the  close  of  the  dis- 
ease. Gowers  states  that  the  cases  in  which  there  is  most  fever  arc 
usually  those  of  rapid  course,  considerable  dropsy,  and  extensive 
hemorrhage* 

As  the  disease  progresses,  weakness  increases;  anaemia  becomes  more 


744  SPECIAL  DIAGNOSIS. 

intense;  dropsy  of  the  subcutaneous  tissues,  peritoneum,  or  pleura 
occurs;  hemorrhages  from  the  nose,  gums,  bowels,  stomach,  lungs, 
or  uterus  further  exhaust  the  patient;  digestion  is  poor,  and  diarrhoea 
is  common. 

Headache  and  tinnitus  are  frequent  symptoms,  occasionally  delirium 
and  coma  may  occur,  and  deafness  is  not  uncommon  toward  the  close 
of  the  disease.     The  eyes  may  be  the  seat  of  leuksemic  retinitis. 

The  liver  is  enlarged,  often  to  a  considerable  degree,  but  without 
special  symptoms.  The  same  is  true  of  the  lymphatic  glands  and  other 
adenoid  tissue.  (Plate  X.,  Fig.  1.)  The  marrow  of  the  bones  becomes 
the  seat  of  disease  in  some  cases,  but  it  does  not  usually  give  rise  to 
symptoms  during  life;  certain  bones,  however,  may  be  tender.1 

The  Blood.  The  most  characteristic  and  important  changes  from 
a  diagnostic  point  of  view  occur  in  the  blood.  The  blood  when  drawn 
from  the  finger  is  strikingly  pale  and  whitish,  an  appearance  supposed 
at  one  time  by  Bennett  to  be  due  to  admixture  of  pus.  It  coagulates 
slowly,  is  of  lower  specific  gravity  than  normal,  and  its  alkalinity  is 
diminished.  When  placed  under  the  microscope  it  is  at  once  seen 
that  the  number  of  white  cells  is  greatly  increased.  If  a  drop  of 
blood  is  mixed  with  some  distilled  water  containing  a  small  quantity 
of  gentian-violet,  the  white  cells  are  stained  a  decided  blue  and  can  be 
picked  out  with  the  greatest  ease.  Instead  of  there  being  one  white 
cell  to  300  or  500  red,  the  ratio  falls  as  low  as  1  :  5,  or  1  :  3,  or  even 
lower.  Authorities  differ  as  to  the  degree  of  increase  necessary  to  dis- 
tinguish leucocythsernia  from  leucocytosis,  some  including  all  in  which 
the  ratio  is  1  :  50  or  lower,  and  others  excluding  those  in  which  the 
ratio  is  greater  than  1  :  20  or  1  :  12.  In  leucocytosis  the  increase  takes 
place  solely  in  the  polynuclear  neutrophilic  leucocytes. 

Not  only  are  the  white  cells  greatly  increased  in  number,  but  they 
vary  considerably  in  size  and  react  differently  to  staining-fluids. 

Ehrlich  has  described  five  varieties  of  leucocytes.  The  pathological 
changes  in  the  normal  leucocytes  in  this  disease  are:  (1)  the  small  mono- 
nuclear elements  are  relatively  diminished;  (2)  the  great  difference  in 
size  of  the  multinuclear  elements;  (3)  the  presence  of  myelocytic  ele- 
ments in  which  the  protoplasm  is  filled  with  fine  neutrophilic  granules; 
(4)  the  presence  of  a  normal  proportion  of  eosinophiles  in  so  extensive 
an  increase  of  leucocytes.2  (Plate  X.,  Fig.  2.)  (5)  Large  mononuclear 
elements  with  karyokinetic  figures  (Miiller).  Satisfactory  study  of  these 
can  be  obtained  only  by  cover-glass  preparations.  The  greatest  care 
should  be  taken  to  have  a  perfectly  clean,  dry  cover-glass,  which 
should  be  handled  with  forceps  to  avoid  moisture  and  soiling.  A 
small  drop  of  blood  is  pressed  between  two  cover-glasses,  as  in  the 
preparation  of  sputum  for  staining.  The  blood  may  be  then  "  fixed" 
by  being  heated  at  a  high  temperature  (120°  C.)  for  some  time,  or  by 
immersion  for  half  an  hour  in  a  solution  of  equal  parts  of  absolute 
alcohol  and  ether.  The  prepared  cover-glass  should  then  be  immersed 
for  a  few  minutes  in  a  solution  of  eosin: 

Eosin 0.5 

Alcohol  (70  per  cent.) 100.0 

1  See  "  A  Case  of  Leucocythceniia,"  Musser  and  Sailer,  Amer.  Journ.  of  the  Med.  Sciences,  1S96. 

2  W.  S.  Thayer :  loc.  cit. 


PLATE    X. 
FIG.  i. 


■ 


<7y 


4fe 


1- .  ■     -<) 


f 


*' 


J* 


TO1 


^ 


1.  Globiferous  cell. 
:i.  Polvnuclear  cell. 


Lymph-gland,  Retroperitoneal  Region. 

Hardened  in  alcohol ;  Rosin's  stain.     X  1500. 

2.  Globiferous  cell  containing-  polynuclear  and  eosinophile  cells. 

4.  Mononuclear  cell.  5.  Globiferous  cell.  6.  Eosinophile  cell. 


*% 


Blood — Leukaemia. 

Hsematoxylin  and  eosin. 

I.  Lymphocyte.  2.  Eosinophile  cell  (mononuclear). 

3.  Polynuclear  leucocyte.  I.  Large  mononuclear  lei cyte  (myelocj  te?) 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       745 

This  solution  should  be  diluted  one-half  before  using.  The  cover- 
glass  should  then  be  dried  and  stained  for  three  or  four  minutes  in  a 
saturated  aqueous  solution  of  niethylene-blue,  also  diluted  one-half 
before  using;  or,  better  still,  for  half  an  hour  to  several  hours  in 
Delafield's  hematoxylin.  (This  hsematoxylin-stain  is  made  in  the 
following  manner  :  To  400  c.c.  of  a  saturated  solution  of  ammonia- 
alum  add  4  grams  of  hsematoxylin-crystals  dissolved  in  25  c.  c.  of 
strong  alcohol.  Leave  this  exposed  to  the  light  and  air  in  an  un stop- 
pered bottle  for  three  or  four  days.  Filter  and  add  100  c.c.  of  gly- 
cerin and  100  c.c.  of  methylic  alcohol.  Allow  the  solution  to  stand 
until  the  color  is  sufficiently  dark.  Then  filter  and  keep  in  a  tightly 
stoppered  bottle.  The  stain  should  ripen  for  at  least  two  months 
before  using.  For  blood-work  the  solution  is  used  in  its  full  strength.) 
By  this  double  stain  the  red  corpuscles  are  stained  red,  the  nuclei 
blue,  the  eosinophile  granules  a  brilliant  red.  Thayer  says  the  fol- 
lowing is  a  satisfactory  modification  of  Ehrlich's  formula  : 

Saturated  aqueous  solution  of  acid  fuchsin 2 

Water 3 

Saturated  aqueous  solution  of  orange  G 6.25 

Saturated  aqueous  solution  of  methyl-green 6 

To  be  added,  drop  by  drop,  while  shaking  the  solution  : 

Water        . 15 

Alcohol 10 

Glycerin 5 

The  specimen,  fixed  as  before,  is  stained  in  this  solution  for  from  two 
to  five  minutes,  washed  in  water,  and  dried  in  the  air,  or,  if  the  speci- 
men has  been  heated  for  an  hour  or  more,  between  filter-paper,  and 
mounted  in  oil  or  balsam.  Specimens  heated  for  one  or  two  hours 
stain  better  than  those  which  have  been  treated  only  a  short  time.  The 
red  cells  appear  orange  or  buff,  the  nuclei  of  the  colorless  corpuscles 
green,  the  neutrophilic  granules  a  violet  or  lilac  color,  the  eosinophilic 
granules  a  deep  red.  The  nuclei  of  nucleated  red  corpuscles,  when 
present,  are  stained  an  intense  deep  green,  almost  black.1 

The  essential  points  in  the  diagnosis  of  leucocythsemia  are:  1.  Such 
an  excess  of  leucocytes  in  the  blood  that  the  ratio  of  white  to  red  falls 
belowT  1  :  50  or  1  :  20;  if  the  ratio  is  higher,  the  white  cells  should 
show  a  progressive  increase.  The  individual  leucoctyes  vary  in  size 
and  characteristics,  as  already  described.  2.  Enlargement  of  the  spleen 
or  lymphatic  glands.  3.  The  occurrence  of  hemorrhages  and  dropsies 
unexplai nablo  by  disease  of  heart,  kidneys,  or  other  organs.  4.  The 
symptoms  of  anaemia  of  a  high  grade,  as  dyspnoea.  5.  Leukemic 
retinitis.  6.  Anaemic  fever.  7.  The  presence  of  the  myelocyte  of 
Ehrlich,  and  nucleated  red  blood-cells.  8.  Specific  gravity  below  1040. 
9.    Excess  of  uric  acid  in  the  urine. 

The  lymphatic  form  of  the  disease  is  rare.  It  is  characterized  by 
enlargement  of  the  lymphatic  glands  and  by  (he  great  increase  in  the 
proportion  of  the  lymphocytes.  The  total  increase  in  the  colorless  ele- 
ments is  not  so  excessive.     Eosinophiles  and  neucleated  red  cells  are 

1  Thayer  :  loc.  cit. 


746  SPECIAL  DIAGNOSIS. 

rare.  The  myelocyte  of  Ehrlich  is  not  present.  A  case  of  a  purely 
myelogenous  form  lias  never  been  authenticated.  Combination-forms 
may  also  occur.  It  must  be  remembered  that  the  number  of  myelocytes 
is  no  indication  of  the  involvement  of  the  bone-marrow. 

In  secondary  or  so-called  splenic  anosmia  we  find  the  same  enlarge- 
ment and  the  general  symptoms,  though  hemorrhage  is  not  so  common. 
Leucocythaemia  is  distinguished  from  it  by  the  great  excess  of  leuco- 
cytes and  by  their  special  characteristics. 

In  lymphadenoma,  or  Hodgkin's  disease,  there  is  extreme  anaemia, 
though  the  excess  of  leucocytes  found  in  leucocythaemia  is  seldom 
reached  and  the  cells  are  smaller.  The  glandular  enlargement  of 
lymphadenoma  is  an  early  and  constant  symptom,  the  spleen  not  being 
much  enlarged.    The  cervical  glands  are  the  ones  usually  first  involved. 

The  duration  of  leucocythaernia  is  usually  two  or  three  years;  but 
some  cases  terminate  in  six  months  or  less,  and  some  last  six  or  seven 
years.  The  size  of  the  spleen  and  the  degree  of  oligocythaemia  appear 
to  have  no  influence.  Gowers  states  that  the  cases  in  which  enlarge- 
ment of  the  lymphatic  glands  is  an  early  symptom  run  a  course  appar- 
ently much  more  acute  than  others,  but  he  admits  that  the  number  of 
such  cases  is  comparatively  small. 

Death  results  most  frequently  from  gradual  loss  of  strength.  Hem- 
orrhage from  various  organs  and  surfaces  is  the  immediate  cause  in 
many  cases.  It  occurs  in  about  three-fourths  of  the  cases,  and,  when 
not  directly  fatal,  increases  the  pre-existing  asthenia.  Diarrhoea  and 
pulmonary  complications  are  not  infrequent  causes  of  death. 

Acute  Leukcemia.  Cases  have  been  described,  especially  in  children, 
in  which  there  is  a  diminution  of  red  cells,  of  haemoglobin.  Nucleated 
red  cells  are  present  as  well  as  an  excess  of  white  blood-corpuscles, 
which  consist  almost  entirely  of  large  mononuclear  elements,  without 
granulation.  There  is  usually  fever,  and  the  disease  runs  a  course 
much  resembling  an  infectious  one.  The  lesions  are  leucocytic  infiltra- 
tion of  the  various  organs. 

Hodgkin's  Disease.  Hodgkin's  disease  (pseudo-leukaemia,  lymph- 
adenoma, or  lymphatic  anaemia)  is  a  disease  characterized  by  enlarge- 
ment of  the  lymphatic  glands  throughout  the  body  and  of  other  adenoid 
tissue  also ;  by  progressive  oligocythsemia  without,  in  most  cases,  much 
increase  of  leucocytes;  and  by  the  development  of  lymphatic  tumors  in 
unusual  situations. 

The  disease  is  most  frequent  in  the  first  half  of  life,  three-fourths 
of  the  cases  being  in  males. 

The  first  symptom  noted  is  enlargement  of  the  glands  of  the  neck; 
but  sometimes  the  inguinal,  less  frequently  the  axillary  glands  are 
first  enlarged;  rarely  the  tonsils  are  the  first  to  be  affected.  The  en- 
largement is  painless  and  progressive,  appearing  first  on  one  side  of 
the  neck  and  extending  under  the  jaw  to  the  opposite  side.  The 
tumors  at  first  are  distinct  and  movable  under  the  skin.  The  swollen 
glands  may  remain  in  this  condition  indefinitely  for  months  or  years; 
but  eventually  they  begin  to  enlarge  very  rapidly,  lose  their  separate 
identity,  and  coalesce  into  large  masses.     Other  glands  in  remote  parts, 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       747 

as  the  axilla  and  groin,  retro-peritoneum,  and  arm,  are  affected.  They 
may  be  soft  and  fluctuating,  or  very  dense  and  hard,  but  heat,  tender- 
ness, suppuration,  and  other  evidences  of  inflammation  are  absent. 

The  spleen  becomes  very  much  enlarged,  but  rarely  attains  the 
dimensions  common  in  leucocythaernia. 

Other  adenoid  tissue  in  the  intestine,  tonsil,  and  posterior  nares,  and 
even  the  thymus,  may  enlarge  and  give  rise  to  pressure-symptoms. 

Fever  is  a  very  constant  symptom,  but  the  type  is  not  constant. 

The  onset  of  the  disease  may  be  marked  by  fever  and  constitutional 
symptoms,  and  the  glandular  enlargement  appear  later.  On  the  other 
hand,  in  three  cases  reported  by  J.  Dreschfeld,1  all  the  patients  enjoyed 
good  health  and  were  able  to  follow  their  work  until  a  few  weeks  before 
death.  In  all,  symptoms  appeared  suddenly  and  consisted  of  pain, 
weakness,  pallor,  loss  of  appetite,  and  pyrexia. 

Coincident  with  the  rapid  and  extensive  enlargement  of  the  glands, 
anaemia  becomes  pronounced  and  is  accompanied  by  the  usual  symp- 
toms. Cough  is  often  associated  with  anaemic  dyspnoea,  and  in  women 
menstruation  may  cease. 

In  addition  to  the  general  symptoms  there  are  numerous  local  ones, 
due  to  the  pressure  or  impairment  of  function — cerebral  ansemia  from 
pressure  on  the  carotids;  cerebral  congestion  from  pressure  on  the  veins 
of  the  neck;  disturbance  of  the  heart  from  pressure  on  the  pneumo- 
gastric;  deafness;  difficulty  in  deglutition  and  mastication;  and  pleural, 
peritoneal,  and  pericardial  effusions. 

The  most  frequent  complications  are  nephritis,  fatty  degeneration  of 
the  heart,  pleurisy,  and,  less  frequently,  pneumonia  and  pericarditis. 

The  duration  of  the  disease  is  from  six  to  eighteen  months.  Two- 
thirds  of  fifty  fatal  cases  referred  to  by  Gowers2  ended  in  less  than 
two  years.  It  is  difficult  to  determine  accurately  the  beginning  of  the 
disease  ;  sometimes  a  long  period  of  latency  follows  the  early  glandular 
swelling;  sometimes  a  general  anaemia  precedes  any  noticeable  swell- 
ing of  the  glands;  and  sometimes  the  disease  runs  an  acute  course, 
ending  fatally  in  two  or  three  months. 

Death  results  most  frequently  from  exhaustion;  but  pressure  upon 
the  trachea  producing  asphyxia  is  not  uncommon,  and  death  has  occurred 
from  starvation,  the  result  of  occlusion  by  pressure  of  the  oesophagus. 
The  complications  already  mentioned  are  the  immediate  causes  of  death 
in  other  cases. 

Scrofulous  enlargement  of  the  glands  presents  the  following  points  of 
difference:  (1)  Scrofula  (tuberculosis)  affects,  as  a  rule,  one  group  of 
glands,  a  local  cause  for  whose  enlargement  is  often  present;  (2)  the 
glands  tend  to  soften,  with  the  formation  of  cheesy  pus,  and  they  may 
be  somewhat  painful ;  (3)  it  affects  children  much  more  frequently  than 
I  [odgkin' a  disease;  (4)  the  persons  affected  exhibit  other  manifestations 
of  so-called  scrofula,  particularly  in  the  eyes,  nose,  skin,  and  joints; 
(5)  the  blood-changes,  particularly  leucocytosis,  do  not  reach  the 
same  intensity  as  in  Hodgkin's  disease;  (6)  the  submaxillary  glands 
are  more  frequently  the  seat  of  scrofulous  adenitis,  whereas  Hodgkin's 

»  British  Med.  Journ.,  April  30,  1892. 

2  Reynolds'  System  of  Medicine,  Philadelphia,  1880,  vol.  iii.  519. 


748  SPECIAL  DIAGNOSIS. 

disease  affects  the  glands  of  the  anterior  and  posterior  cervical  triangles. 
Leueocythcemia  is  distinguished  by  the  great  enlargement  of  the  spleen, 
the  enlargement  of  the  liver,  and  the  characteristic  blood-changes. 

Addison's  Disease.  Addison's  disease  is  characterized  by  a  grad- 
ual loss  of  strength  without  much  loss  of  flesh;  by  gastric  uneasiness 
and  occasional  vomiting;  feeble  circulation;  and  a  bronze  hue  of  the 
skin.  The  only  fairly  constant  anatomical  lesion  is  that  of  the  supra- 
renal bodies. 

The  disease  occurs  most  frequently  during  the  active  period  of  life, 
from  the  age  of  twenty  to  forty  years,  and  nearly  twice  as  often  in  males 
as  in  females.  It  is  thought  by  some  to  be  tuberculous  in  nature; 
some  cases  seem  to  have  followed  injuries. 

The  disease  begins  insidiously  with  gradual  and  progressive  loss  of 
strength.  It  becomes  evident  from  the  patient's  languor,  weariness 
on  slight  exertion,  and  inaptitude  for  mental  effort  that  he  is  suffering 
with  some  exhausting  disease.  The  appetite  is  impaired  or  lost,  there 
is  more  or  less  discomfort  at  the  epigastrium,  and  occasional  vomiting. 

Perhaps  at  this  time  a  close  inspection  may  show  some  discoloration 
of  the  skin,  but  usually  this  appears  later.  By  degrees  the  gastric 
symptoms  become  more  prominent,  and  vomiting  may  be  so  frequent  as 
to  shorten  life  materially.  The  most  characteristic  symptom  is  the 
extreme  prostration  without  any  obvious  cause.  Any  exertion  requires 
great  effort  and  may  induce  fainting.  Finally,  the  patient  is  unable 
to  leave  the  bed.  Dull  pains  in  the  head,  back,  and  abdomen  are  not 
uncommon;  neuralgic  pains  in  the  limbs  may  be  complained  of;  and 
Osier  states  that  there  is  tenderness  on  pressure  in  the  lumbar  region, 
in  a  considerable  proportion  of  cases. 

The  pulse  is  extremely  small  and  feeble;  in  the  later  stages  it  may 
be  absent  at  the  wrist. 

The  discoloration  of  the  skin  is  the  most  striking  symptom  of  the 
disease  when  it  is  well  marked.  Sometimes  the  whole  body  becomes 
of  a  walnut-juice  color,  a  bronzing  which  is  deeper  in  exposed  surfaces, 
as  the  face,  neck,  and  hands,  and  wherever  there  is  naturally  a  deposit 
of  pigment,  as  the  axilla  and  the  genitals.  At  times  only  portions  of 
the  body  are  discolored,  in  which  case  the  dark  hue  shades  off  gradually 
into  the  normal  hue  of  the  skin.  The  pigmentation  may  extend  to  the 
mucous  membrane  of  the  mouth,  eye,  and  vagina.  Wilks1  states  that 
in  all  the  cases  which  he  has  seen  the  scalp,  finger-nails,  soles  of  the 
feet,  and  palms  of  the  hands  escaped  pigmentation. 

Nevertheless  discoloration  of  the  skin  is  not  an  essential  symptom 
of  the  disease;  in  some  cases  it  is  entirely  absent.  These  cases,  espe- 
cially if  associated  with  much  vomiting,  run  a  more  acute  course  than 
the  others,  lasting  only  a  few  weeks.  Such  cases  have  been  mistaken 
for  typhus  fever. 

The  diagnostic  symptoms  are  progressive  asthenia,  causeless  nausea 
and  vomiting,,  and  bronzing  of  the  skin  and  mucous  membranes. 

The  duration  of  the  disease  is  usually  from  six  months  to  two  years; 


1  Reynolds'  System  of  Medicine,  Philadelphia,  1880,  iii.  561. 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS.       749 

but  some  cases  have  lasted  from  six  weeks  to  ten  years,  and  others,  as 
already  stated,  prove  fatal  in  a  few  weeks.  Death  results  usually  from 
asthenia,  but  it  may  also  occur  suddenly  from  syncope,  or  in  coma  and 
convulsions. 

The  differential  diagnosis  is  from  (1)  jaundice;  (2)  from  the  pig- 
mentation occurring  in  abdominal  tumors;  (3)  from  the  pigmenta- 
tion of  pregnancy  and  chronic  uterine  disease;  (4)  from  melanotic 
cancer;  (5)  vagabond' s  disease ;  (6)  and  leucoderma. 

Exophthalmic  Goitre.  Exophthalmic  goitre,  Graves'  or  Basedow's 
disease,  is  a  disease  characterized  by  (1)  great  rapidity  of  the  heart's 
action;  (2)  enlargement  of  the  thyroid;  (3)  prominence  of  the  eyes; 
(4)  muscular  tremor  (Marie);  (5)  vomiting  and  diarrhoea,  chiefly  the 
latter,  without  cause;  (6)  restless  nervous  excitement  (Charcot);  (7) 
insufficiency  of  nutrition  (Mobius);  (8)  superficial  respiration  (Bryson). 

It  is  far  more  frequent  in  women  than  in  men.  It  may  develop  at 
any  age,  but  is  most  common  in  early  adult  life.  The  particular  cause 
is  unknown,  though  it  is  probably  located  in  the  medulla.  A  neurotic 
heredity,  exhausting  disease,  general  debility,  and  anaemia  are  predis- 
posing causes,  while  sudden  fright  or  shock  is  the  most  common  excit- 
ing cause. 

Of  the  three  classic  symptoms,  rapidity  of  the  heart's  action,  with 
palpitation,  enlargement  of  the  thyroid,  and  prominence  of  the  eyes  (ex- 
ophthalmos), the  first  is  the  essential  symptom.  It  is  also  usually  the 
earliest.  Either  enlargement  of  the  thyroid  or  exophthalmos  may  be 
absent  for  months  or  years,  and  in  some  instances  throughout  the 
disease. 

1.  Graves'  disease  begins  slowly.  Attacks  of  palpitation  may  recur 
at  intervals  for  a  long  time  before  their  true  nature  is  suspected.  In 
these  attacks  the  behavior  of  the  heart  is  much  like  that  which  occurs 
under  the  influence  of  fright  or  great  excitement.  The  frequency  may 
not  be  over  100  or  120  in  the  early  attacks,  the  rate  being  normal  in 
the  intervals.  In  the  later  and  severe  attacks,  however,  the  pulse 
beats  160  or  180  or  even  200.  It  is  small  and  regular.  The  heart 
beats  with  increased  force;  the  sounds  are  loud,  sharp,  and  clear/occa- 
sionally being  heard  several  feet  from  the  patient.  In  time  the  heart 
becomes  hypertrophied  and  dilated,  and  there  is  often  a  loud  basic 
systolic  murmur. 

The  larger  arteries  and  even  sometimes  the  smaller  ones  show  the 
vascular  disturbance  by  increased  pulsation,  sometimes  with  thrill. 

2.  The  thyroid  is  usually  the  next  to  become  affected.  It  enlarges 
slowly  from  vascular  dilatation,  the  swelling  at  first  subsiding  in  the 
intervals  between  attacks,  but  subsequently  persisting.  The  right  lobe 
may  be  larger  than  the  left.  The  enlargement  is  painless,  soft,  and 
compressible.  It  may  pulsate  with  or  without  thrill,  and  over  it  can 
be  heard  hsemic  murmurs. 

3.  Prominence  of  the  eyes  is  the  most  conspicuous  feature  of  well- 
marked  cases.  Like  enlargement  of  the  thyroid  it  varies  in  degree, 
and  rarely  is  wholly  absent.  The  protrusion  allows  the  white  sclerotic 
to  show  above  and  below  the  cornea,  giving  the  eyes  an  unnatural, 


750  SPECIAL  DIAGNOSIS. 

startled,  staring  appearance.  The  protrusion  may  be  so  great  that  the 
eyelids  cannot  close;  more  commonly  they  close,  but  when  the  eyeball 
is  simply  directed  downward  the  upper  eyelids  do  not  follow,  but 
remain  spasmodically  elevated  or  lag  behind  the  movement  of  the  eye- 
ball (Von  Graefe's  symptom).  The  eyeball  may  become  inflamed 
and  even  slough  from  undue  exposure.  In  rare  instances  one  eyeball 
alone  is  affected,  and  in  these  cases  the  lobe  of  the  thyroid  of  the 
opposite  side  is  enlarged. 

In  addition  to  these  characteristic  symptoms  the  patient  loses  flesh 
and  strength,  has  moderate  pyrexia  of  irregular  type,  suffers  from 
impaired  appetite,  diarrhoea,  and  despondency.  The  diarrhoea  is  of 
the  nervous  type— increased  peristalsis  without  local  catarrh.  Men- 
struation is  apt  to  be  irregular  or  to  cease.  Tinnitus  aurium,  headache, 
and  vertigo  are  not  uncommon,  and  sometimes  there  is  profuse  sweat- 
ing. Muscular  tremor,  occurring  on  voluntary  movement,  is  frequently 
observed,  and,  with  diarrhoea,  is  almost  as  common  as  the  three  primary 
symptoms.  (Edema  of  the  feet  is  often  seen  if  there  is  coexisting 
mitral  disease.  Transitory  vasomotor  oedema  of  the  eyelids,  the  face, 
hands,  and  the  supra-  and  infraclavicular  regions  occurs.  It  is  usually 
circumscribed,  and  may  not  pit  on  pressure. 

Graves'  disease,  as  a  rule,  runs  a  chronic  course,  lasting  for  years. 
A  few  cases  that  have  run  an  acute  course  of  a  few  weeks,  some  end- 
ing in  recovery  and  some  in  death,  have,  however,  been  reported. 
Moreover,  there  may  be  recurring  attacks  with  apparent  recovery  in 
the  intervals.  Recovery  is  thought  to  occur  in  about  one-fourth  of  the 
cases.  Gowers  states  that  it  is  most  frequent  in  the  cases  that  develop 
rapidly  and  in  which  the  cardiac  symptoms  preponderate  over  those 
in  the  neck  and  eyes,  and  that  complete  recovery  is  very  rare  when 
there  is  much  enlargement  of  the  thyroid  and  much  prominence  of  the 
eyes. 

Death  results  from  gradual  weakening  of  the  heart  and  its  direct 
and  indirect  effects.  It  may  be  hastened  also  by  uncontrollable  diar- 
rhoea, acute  mania,  and  epilepsy.  The  disease  may  also  be  complicated 
with  hemorrhages,  and  these  be  the  immediate  cause  of  death. 


CHAPTER   IX. 

CONSTITUTIONAL  DISEASES. 

The  modern  enthusiastic  and  extensive  researches  in  morbid  anatomy 
and  histology  and  in  bacteriology  have  for  the  time  being  pushed  to 
the  background  affections  which,  although  they  possess  a  distinct  entity, 
are  more  vague  and  recondite.  The  occurrence  of  morbid  processes 
behind  which  as  a  causal  factor  a  constitutional  state  exists,  as  hemor- 
rhages in  haemophilia  or  gastro-intestinal  catarrh  in  rhachitis,  must  not 
be  forgotten.  The  occurrence  of  abnormal  phenomena,  with,  or  without 
a  cognizable  local  morbid  process,  should  always  call  for  the  considera- 
tion of  a  possible  general  condition,  or  diathesis,  as  it  was  formerly 
termed,  before  the  diagnosis  is  fully  concluded.  In  a  case  of  fever, 
for  instance,  we  aim  too  often  to  determine  the  infection  and  its 
character,  whereas  an  infective  process  may  not  be  present,  the  fever 
being  due  to  other,  possibly  constitutional,  causes. 

Advance  in  the  science  of  medicine  has  transferred  anaemia  and 
chlorosis,  formerly  considered  to  be  constitutional  diseases,  to  the 
domain  of  blood  diseases.  Syphilis,  tuberculosis,  and  probably  cancer 
are  now  known  to  be  infectious  diseases.  The  field  has  been  narrowed; 
doubtless  it  will  be  obliterated  as  our  knowledge  of  constitutional 
affections  become  more  precise. 

Rheumatic  Fever. 

An  acute,  general,  febrile,  non-contagious  disease,  characterized  by 
specific  inflammation  of  the  joints  and  their  contiguous  structures, 
hence  called  acute  articular  rheumatism.  It  is  further  characterized  by 
a  tendency  of  the  inflammation  to  involve  the  larger  joints  successively, 
to  skip  from  one  joint  to  another,  and  to  be  associated  with  endo-  and 
pericarditis. 

The  predisposing  causes  of  rheumatic  fever  are  heredity,  which  is 
operative  in  25  or  30  per  cent,  of  the  cases;  age — 81  per  cent,  of  first 
attacks  occur  between  the  eleventh  and  thirtieth  years  (Pye-Smith); 
sex,  in  childhood  girls  arc  more  frequently  affected  than  boys,  but  after 
that  period  sex  appears  to  have  no  influence.  Polyarticular  inflamma- 
tions, sometimes  rheumatic  in  nature,  are  met  with  during  convalescence 
from  scarlatina  and  dysentery.  They  also  occur  in  association  with  the 
puerperal  state  and  gonorrhoea,  in  which  they  are  probably  pysemic. 
The  nature  of  the  polyarthritis  which  occurs  in  connection  with  dengue 
and  haemophilia  is  obscure. 

Damp,  changeable  weather  appears  to  be  more  potent  as  an  exciting 
cause  than  very  cold  weather.  It  is  especially  effective  when  the  sys- 
tem is  depressed  from  any  cause.  The  disease  occurs,  however,  at  all 
seasons  and  in  all  climates. 


752  SPECIAL  DIAGNOSIS. 

Symptoms.  The  onset  of  the  disease  is  not  characterized  by  con- 
stant symptoms.  Sometimes  the  fever  and  joint-inflammations  are  pre- 
ceded a  day  or  two  by  debility,  wandering  pains  in  the  joints  or  muscles, 
and  loss  of  appetite.  In  other  cases  there  is  a  chill  or  repeated  attacks 
of  chilliness,  followed  in  a  day  or  two  by  fever  and  inflammation  of 
the  joints.  In  rare  cases  the  onset  may  be  followed  not  by  inflamma- 
tion of  the  joints,  but  by  inflammation  of  the  serous  membranes,  par- 
ticularly those  of  the  heart  and  its  sac. 

The  temperature  may  rise  a  day  or  two  before  there  are  any  joint- 
symptoms,  or  fever  and  arthritis  may  begin  almost  simultaneously. 
The  temperature  rises  rapidly  to  102°,  103°,  or  104°  F.,  and  one  or 
more  of  the  larger  joints,  generally  the  knee  and  ankle,  become  pain- 
ful, tender,  swollen,  and  hot.  There  may  be  great  pain  on  motion 
before  there  is  evident  swelling  or  much  local  tenderness.  The  pain 
varies  from  mere  discomfort  to  the  most  excruciating  suffering.  It  is 
always  aggravated  by  motion  or  pressure,  and  is  at  times  so  exquisite 
that  the  slightest  touch,  the  weight  of  bedclothing,  or  the  jar  of  the 
bed  from  a  heavy  step  in  the  room  makes  the  patient  cry  out.  It  may 
extend  beyond  the  joint  to  neighboring  tendons  and  nerves.  The  swell- 
ing likewise  varies  greatly;  sometimes  there  is  only  slight  puffiness 
with  increased  distinctness  of  the  cutaneous  veins,  increased  heat  in 
the  part,  but  no  general  redness;  in  other  cases  there  is  considerable 
swelliug  about  the  joint  so  that  the  bony  prominences  are  obliterated, 
the  surface  being  tense,  red,  and  very  hot  to  the  touch.  There  is  often 
effusion  into  the  joint.  Swelling  is  most  marked  in  the  wrist  and  ankle, 
and  less  so  in  the  shoulders,  hips,  elbows,  and  knees. 

Multiplicity  of  joints  affected.  A  characteristic  peculiarity  of  rheu- 
matism is  its  tendency  to  involve  one  joint  after  another.  One  or  sev- 
eral joints  may  be  affected  at  first;  it  is  very  common  for  the  right 
ankle  to  be  affected,  and  then  in  a  short  time  the  opposite  ankle,  fol- 
lowed bv  the  left  knee  and  right  knee,  and  so  on  with  the  other  joints. 
The  inflammation  usually  lasts  in  each  joint  from  two  to  four  days. 
The  process  may  subside  in  one  articulation  and  begin  in  another  with 
startling  rapidity.  At  one  visit  of  the  physician  the  patient's  right 
ankle  may  be  swollen,  hot,  and  unbearably  painful,  and  on  the  next 
day  the  right  ankle  may  be  quite  well  again  and  the  patient  be  found 
suffering  acute  pain  in  the  right  knee  or  left  ankle. 

The  pulse  in  the  early  stage  of  rheumatism  is  moderately  accelerated 
(99  to  110)  ;  it  is  regular,  of  good  volume,  often  bounding,  and  some- 
times hard.  The  urine  is  scanty,  high-colored,  abnormally  acid,  and 
deposits  on  cooling  a  copious  precipitate  of  urates,  resembling  red  sand 
in  appearance.  The  skin  does  not  feel  so  hot  as  one  would  expect  from 
the  temperature.  It  is  continually  covered  with  a  copious,  acid,  and 
somewhat  pungent  perspiration.  Nervous  symptoms  are  not  marked. 
There  may,  however,  be  slight  nocturnal  delirium.  Sleeplessness  from 
pain  is  very  common. 

The  temperature  in  rheumatic  fever  is  not  usually  very  high  ;  it  is 
much  oftener  under  than  over  103°.  In  rare  cases,  however,  espe- 
cially when  the  fever  is  complicated  with  pericarditis,  pneumonia,  or 
some  disturbance  of  the  heat-regulating  apparatus,   the  temperature 


CONSTITUTIONAL  DISEASES.  753 

may  attain  the  extraordinary  range  of  106°-112°  F.  Such  high  tem- 
peratures may  occur  suddenly  or  gradually,  and  are  sometimes  attended 
with  marked  brain-symptoms  (so-called  cerebral  rheumatism). 

Endocarditis  aud  pericarditis  may  occur  at  any  period  of  rheumatic 
fever;  they  may  even  precede  any  joint-inflammation.  They  are  most 
common,  however,  in  the  first  two  weeks  of  the  disease.  The  younger 
the  patient  and  the  more  severe  the  attack,  the  greater  the  liability 
to  heart-complication.  They  occur  in  about  one-fourth  of  all  cases. 
Endocarditis  is  most  common;  often  it  is  the  only  lesion,  but  some- 
times it  is  associated  with  pericarditis,  and  more  rarely  with  myocar- 
ditis. These  complications  usually  give  rise  to  no  symptoms  at  first. 
Hence  the  heart  should  be  examined  daily.  A  seuse  of  constriction 
in  the  prsecordia  or  pit  of  the  stomach,  an  anxious  expression  of  the 
face  with  pallor,  a  change  in  the  frequency,  but  especially  in  the 
rhythm  of  the  pulse,  and  the  occurrence  of  cough  or  dyspnoea,  should 
attract  attention  to  the  heart.  The  physical  signs  of  the  respective 
lesions  have  been  described  fully  under  Diseases  of  the  Heart. 

The  setting  in  of  convalescence  from  rheumatic  fever  is  marked  by 
cleaning  of  the  tongue,  which  also  becomes  less  red,  and  increase  in 
the  secretion  of  urine,  which  remains  of  high  specific  gravity.  The 
fever  subsides  gradually,  the  joints  cease  to  be  red,  swollen,  and  tender, 
the  acid  sweats  lessen,  and  the  appetite  improves.  In  proportion  to 
the  duration  of  the  case  and  its  severity  the  patient  is  left  with  debility 
and  marked  anaemia,  both  red  cells  and  haemoglobin  being  diminished. 
In  anaemic  cases  a  hsemic  murmur  may  be  heard  over  the  base  of  the 
heart.  In  some  cases  acute  dilatation  has  been  observed,  with  a  tri- 
cuspid murmur. 

Complications  and  Sequels.  Apart  from  heart-complications 
which  have  been  mentioned,  pleuritis,  pneumonia,  and  bronchitis  occur 
in  from  10  to  15  per  cent,  of  the  cases.  They  are  frequently  bilateral, 
and  are  very  much  more  common  in  rheumatic  fever  with  pericarditis 
or  endocarditis  than  in  simple  rheumatic  fever.  Moreover,  the  pul- 
monary complications  are  frequently  latent,  and  would  be  overlooked 
but  for  the  daily  physical  examination  of  the  chest.  On  the  other 
hand,  they  may  develop  with  great  suddenness,  and  what  appeared  to 
be  a  full-blown  pneumonia  may  subside  suddenly  as  a  fresh  joint  is 
affected.  They  behave  more  like  sudden  active  congestions  than  true 
pneumonias.  Rheumatic  pleurisies  are  characterized  by  the  rapidity 
with  which  effusion  takes  place,  the  persistence  of  pain  in  the  side 
during  effusion,  the  tendency  to  involve  both  sides  in  succession, 
the  readiness  with  which  the  effusion  is  absorbed,  and  their  acute 
course. 

Nervous  System.  The  most  common  complication  of  the  nervous 
system  is  delirium,  which  is  generally  associated  with  insomnia  and 
hyperpyrexia,  but  the  latter  is  not  constant.  These  brain-symptoms 
geuerally  appear  in  the  second  week  of  illness,  and  about  the  time  of 
convalescence,  or  while  the  joints  are  still  inflamed.  The  delirium  may 
be  low  and  muttering,  accompanied  by  ataxic  symptoms  or  even  by  tre- 
mors and  spasms  of  muscles;  or  it  may  be  furious.  In  favorable  cases 
a  deep  sleep  ushers  in  recovery,  or,  in  unfavorable  cases,  the  delirium 

48 


754  SPECIAL  DIAGNOSIS. 

persists  with  adynamia,  the  patient  dying  in  collapse  or  coma,  preceded 
or  not  by  convulsions. 

Chorea  sometimes  occurs  as  a  complication,  but  it  is  more  common 
as  a  sequel  of  mild  cases  in  children.  Cerebral  meningitis  occurs 
occasionally,  especially  when  there  is  ulcerative  endocarditis.  Cere- 
bral embolism  is  another  rare  complication. 

Various  spinal  symptoms  occur  in  some  cases,  at  times  with,  and 
at  times  without,  demonstrable  lesion  of  the  cord  or  its  membranes. 
Tetanus,  myelitis,  and  spinal  meningitis  may  all  be  simulated.  Per- 
haps these  symptoms  are  due  to  high  temperature;  but  very  high  tem- 
peratures are  met  with  without  the  occurrence  of  any  cerebral  or  spinal 
symptoms. 

Nephritis  is  rare,  but  sometimes  hemorrhage  into  the  kidney  occurs 
with  its  usual  symptoms.      Peritonitis  is  extremely  rare. 

Various  erythematous  skin-eruptions  are  seen  from  time  to  time,  and 
occasionally  purpura.  Subcutaneous  nodosities  have  been  described 
by  several  writers.  They  are  attached  to  the  tendons,  fascia,  and  peri- 
osteum, and  are  most  frequent  on  the  back  of  the  elbow,  the  ankles, 
and  patella.  They  are  painless  and  may  occur  in  any  form  of  rheu- 
matism. 

Diagxosis.  Rheumatic  fever  is  distinguished  from  gout  by  the  pro- 
fuse acid  and  acrid  sweating,  the  tendency  to  involve  a  number  of 
joints  and  particularly  the  larger  ones,  by  the  greater  intensity  of  con- 
stitutional symptoms,  by  the  great  liability  to  heart-complications,  and 
by  the  absence  of  uric  acid  from  the  blood. 

It  is  distinguished  from  pycemia  by  the  wandering  character  of  the 
inflammation;  the  acid  sweats;  the  absence  of  any  antecedent  condition 
which  would  develop  purulent  foci — such  as  inj  uries,  abscesses,  or 
specific  eruptive  fever;  the  absence  of  chills,  and  the  fact  that  in  rheu- 
matic fever  the  sweats  are  constant,  whereas  in  pyaemia  they  follow  a 
fall  in  the  temperature.  Cutaneous  abscesses  do  not  occur  in  rheuma- 
tism, and  after  its  subsidence  the  joint's  usefulness  is  not  impaired. 

Acute  synovitis  resembles  rheumatic  fever,  because  in  both  occur  the 
symptoms  of  pain,  tenderness,  and  swelling  in  connection  with  a 
joint.  Usually,  however,  in  synovitis  but  one  joint  is  involved,  and 
there  is  a  history  of  exposure  to.  cold  or  injury.  The  effusion  is 
limited  to  the  synovial  sac  of  the  joint,  is  frequently  abundant,  and 
fluctuation  can  easily  be  detected.  The  constitutional  symptoms  are 
much  less  marked  than  in  rheumatism. 

Milk-leg  or  phlegmasia  alba  dolens  differs  from  rheumatism  in  that 
it  usually  occurs  in  women  after  confinement,  or  as  a  complication  or 
sequel  of  fever,  as  typhoid  fever.  Usually  one  leg  is  affected,  or  part 
of  the  leg,  especially  the  calf.  This  becomes  tense,  tender,  uniformly 
swollen,  and  the  seat  of  great  pain.  The  leg  is  moved  with  much 
difficulty.  The  femoral  vein  may  beiound  to  be  knotted  and  tender. 
There  is  almost  always  evidence  of  antecedent  disease. 

Acute  periostitis  when  close  to  a  joiut  simulates  rheumatism.  But  the 
tenderness  and  heat  are  not  in  the  joint  itself,  they  are  superficial,  and 
are  associated  with  less  swelling.  Pitting  on  pressure  is  common;  and 
circumscribed  fluctuation  usually  discloses  the  presence  of  suppuration. 


CONSTITUTIONAL  DISEASES.  755 

Pyemic  symptoms  are  added  to  the  local  symptoms,  particularly  if 
osteitis  or  osteomyelitis  is  present. 

The  articular  symptoms  of  glanders  are  to  be  distinguished  by  the 
occupation  of  the  patient,  the  mode  of  onset,  the  associated  symptoms, 
especially  one  or  more  pustules,  and  the  fact  that  the  painful  joints  are 
not  so  apt  to  be  swollen  and  red  as  in  rheumatic  fever. 

In  syphilis  joint-pains  frequently  occur,  but  their  character  is  made 
out  by  the  fact  that  the  joints  are  not  inflamed,  and  that  the  pain  is 
much  worse,  or  occurs  only  at  night,  and  by  the  history  of  the  patient 
and  the  therapeutic  test. 

In  diseases  of  the  brain  and  spinal  cord  joint-inflammations  of 
trophic  origin  occur.  They  are  distinguished  by  the  coexistence  of  some 
lesion  of  brain  or  cord,  with  hemiplegia  or  other  palsy,  and  of  other 
trophic  changes,  such  as  bedsores,  atrophied  muscles,  loss  or  excessive 
growth  of  hair,  shiny  skin,  and  defective  growth  of  nails. 

Subacute  Articular  Rheumatism. 

In  some  instances  the  joint-inflammation  is  less  severe  and  is  accom- 
panied by  only  slight  fever.  One  or  more  joints  may  be  affected.  It 
differs  from  the  ordinary  form  in  being  milder  in  degree  and  more 
persistent,  lasting  sometimes  for  months.  It  is  generally  subacute 
from  the  beginning,  but  may  be  the  type  present  in  those  who  have 
had  several  attacks  of  rheumatic  fever  and  have  been  left  in  a  very 
sensitive  condition.  Rheumatic  fever  is  usually  subacute  in  children, 
and  often  only  one  joint  is  involved.  Cardiac  complications  are  more 
frequent  than  in  adults,  and  chorea  may  occur  as  a  sequel.  Erythema 
nodosum  and  subcutaneous  nodosities  are  more  common  in  children. 

Chronic  Articular  Rheumatism.  In  this  form  the  patient  has 
pain  and  stiffness  in  one  or  more  joints,  or  in  the  contiguous  tissues. 
The  joints  most  frequently  affected  are  the  shoulder  and  knee.  The 
pain  is  more  or  less  constant,  but  worse  in  damp  weather  or  on  the 
approach  of  a  storm,  worse  also  at  night  in  a  good  many  cases.  Con- 
versely, it  is  better  in  warm,  dry  weather.  There  is  not  much,  if  any, 
tenderness,  and  rarely  any  swelling  or  elevation  of  temperature.  The 
joints  very  frequently  crack  aud  grate  on  motion.  In  the  interval  of 
attacks  there  is  no  impairment  of  the  usefulness  of  the  joints.  In 
very  chronic  cases  there  may  be  some  atrophy  of  muscles  and  perma- 
nent stiffness,  even  fibrous  ankylosis. 

In  some  cases  there  are  repeated  attacks  of  subacute  articular  rheu- 
matism, accompanied  by  the  usual  symptoms  and  joint-effusions. 

Chronic  articular  rheumatism  is  distinguished  from  chronic  gout  by 
the  fact  that  there  is  no  special  tendency  to  involve  the  great  toe,  by 
the  absence  of  the  deformities  resulting  from  gout,  and  the  absence  of 
deposits  of  sodium  urate  in  the  ears,  fingers,  and  around  the  joints. 

Muscular  Rheumatism. 

In  this  variety  of  rheumatism  there  is  pain  in  the  affected  muscles, 
which  often  comes  on  suddenly  in  the  night,  or  is  first  noticed  when 


756  SPECIAL  DIAGNOSIS. 

the  patient  attempts  to  rise  in  the  morning.  The  pain  when  the  patient 
is  at  rest  may  be  inconsiderable,  rarely  amounting  to  more  than  a  dull, 
aching,  sore  feeling;  on  attempting  to  move,  to  bend,  or  twist,  or 
straighten  himself,  however,  the  patient  catches  himself  suddenly  on 
account  of  the  agonizing  tearing  or  burning  pain.  When  the  muscles 
are  relaxed  the  patient  is  fairly  comfortable.  Sudden  movement  is  the 
most  painful.  The  affected  muscles  are  tender  to  touch  and  to  sharp 
blows.  Muscular  rheumatism  may  be  acute  or  chronic.  In  the  latter 
the  symptoms  are  very  like  those  of  chronic  articular  rheumatism, 
except  that  the  muscles  and  not  the  joints  are  affected.  There  is 
the  same  proneness  to  recur  in  unfavorable  weather  and  in  cold,  damp 
seasons. 

The  disease  receives  different  names  according  to  the  muscle  affected. 
The  most  common  subyarieties  are:  lumbago,  in  which  the  muscles 
of  the  small  of  the  back  are  affected;  pleurodynia,  in  which  the  inter- 
costal muscles  suffer;  and  torticollis,  in  which  the  sterno-mastoid  and 
trapezius  are  painfully  contracted. 

In  lumbago  the  patient  holds  himself  rigid  and  is  unwilling  to  rotate 
the  trunk  upon  the  vertebras.  Often  the  most  comfortable  position  is 
that  in  which  he  sits  and  bends  slightly  forward  over  another  chair. 
Motion  is  painful,  but  pressure  is  not.  Fever  is  absent.  There  is  a 
history  of  repeated  attacks,  or  of  exposure,  such  as  lying  upon  damp 
ground.  Lumbago  needs  to  be  distinguished  from  disease  of  the  spinal 
membranes,  from  disease  of  the  vertebrse,  aneurism,  abdominal  abscess, 
and  diseases  of  the  uterus  and  ovaries.  The  diagnosis  of  rheumatism 
is  arrived  at  by  exclusion. 

In  pleurodynia  there  is  usually  tenderness  upon  pressure  as  well  as 
upon  motion  and  deep  inspiration.  The  pain  is  of  the  same  sore, 
burning  character,  aggravated  by  coughing  and  sneezing.  The  patient 
breathes  as  little  as  possible,  and  often  bends  over  toward  the  affected 
side  to  lessen  the  motion.  Pleurodynia  is  distinguished  from  pleurisy 
by  the  absence  of  fever,  cough,  and,  above  all,  of  friction-sounds.  In 
intercostal  neuralgia  there  are  painful  points  upon  pressure,  whereas  in 
pleurodynia,  firm  pressure  is  grateful,  though  tapping  is  painful. 

In  torticollis  the  head  is  drawn  to  one  side  and  fixed  in  that  position. 
The  sterno-mastoid  especially  is  rigid  and  tender  on  pinching.  In 
spinal  affections  the  head  is  retracted,  and  there  are  antecedent  symp- 
toms as  headache,  and  darting  pains  with  fever. 

Rheumatoid  Arthritis. 

Rheumatoid  arthritis  or  rheumatic  gout  is  an  affection  characterized 
by  acute  or  chronic  inflammation  of  the  joints,  of  progressive  charac- 
ter, and  resulting  in  deformities.  It  is  attended  with  very  little  fever, 
and  occurs  apart  from  any  known  systemic  disease. 

It  may  be  acute  or  chronic.  The  acute  form  differs  but  little  in  its 
manifestations  from  acute  rheumatic  fever.  Several  joints  are  enlarged, 
tender,  and  painful.  Constitutional  symptoms,  such  as  fever,  loss  of 
appetite,  frequent  pulse,  thirst,  furred  tongue,  occur  as  in  rheumatism. 
Profuse  acid  sweats,  however,  are  absent,  and   so  is  the  tendency  to 


CONSTITUTIONAL  DISEASES.  757 

serous  inflammations.  Moreover,  while  the  larger  joints,  as  in  rheu- 
matism, may  be  affected,  the  smaller  ones  also,  especially  of  the  fingers 
and  toes,  are  inflamed  and  often  the  seat  of  serous  effusions.  Further- 
more, the  inflammation  persists  in  the  affected  joints  and  does  not  jump 
from  one  to  another.  Instead  of  disappearing  in  a  few  weeks,  it  drags 
on  for  a  much  longer  time.  The  pain  subsides,  but  the  swelling  per- 
sists, and  permanent  deformity  results  in  at  least  some  of  the  joints. 
The  muscles  of  the  arms  and  legs  waste  and  are  affected  with  painful 
spasms. 

The  disease  is  most  common  in  young  women  exhausted  by  repeated 
pregnancies  or  prolonged  lactation,  and  is  favored  by  poverty,  priva- 
tion, and  cold. 

The  chronic  form  is  much  more  common.  It  also  attacks  most  fre- 
quently young  women  who  are  exhausted  or  are  subjected  to  great 
fatigue.  There  is  pain,  numbness,  Or  formication  in  a  joint,  as  the  knee. 
The  joint  becomes  tender,  painful,  and  may  be  slightly  swollen.  This 
subsides  after  a  while,  but  sooner  or  later  the  same  joint  or  another 
one  becomes  affected,  the  process  is  persistent,  one  joint  after  another 
is  attacked,  and  gradually  all  the  joints  may  become  greatly  distorted, 
enlarged,  and  the  seat  of  contractions.  There  may  be  no  impairment 
of  general  health,  or,  at  most,  only  dyspeptic  symptoms.  The  progress 
is  interrupted  by  remissions  from  time  to  time.  Pain  may  be  severe 
and  subject  to  nocturnal  exacerbations.  The  shape  of  the  joints  is 
altered  by  the  effusion  into  the  joints  and  adjacent  bursse,  by  thicken- 
ing of  the  tissues  around  the  joints,  growths  of  new  bone  on  the  joint- 
extremity  of  the  bones,  absorption  of  the  articular  cartilages  and 
growths  of  new  cartilage  in  the  synovial  sheaths,  relaxation  of  liga- 
ments, muscular  contractures,  and  luxation  of  the  joints.  The  joints 
crack  and  creak  like  rusty  hinges,  are  sore  and  stiff,  and  the  attached 
muscles  are  affected  with  painful  cramps. 

Great  enlargement  of  the  joints  at  times  occurs  from  the  causes 
already  mentioned  and  from  infiltration  of  the  overlying  tissues.  The 
enlargement  is  rendered  more  conspicuous  by  the  atrophy  of  adjacent 
muscles. 

In  addition  to  the  articular  symptoms,  other  phenomena  attend  the 
process.  One  of  the  more  common  is  increased  frequency  of  the  pulse. 
Although  the  patient  is  afebrile,  the  average  pulse-rate  is  100  to  120, 
or  even  more.  Moreover,  the  pulse  is  soft  and  compressible,  in  con- 
tradistinction to  the  pnlse  of  gout  and  rheumatism.  It  is  worth  noting 
that  a  return  to  the  normal  frequency  is  a  sign  that  the  process  of  the 
disease  is  arrested,  although  the  joint-lesions  remain. 

The  skin  is  characteristic.  It  is  soft  and  often  much  freckled,  while 
the  complexion  is  fair.  C.  T.  Griffiths  has  observed  the  pigmentary 
cutaneous  changes,  along  with  neural  symptoms,  prior  to  the  joint-man- 
ifestations, and  describes  two  forms:  a  diffuse  melasmic  discoloration, 
and  dark-brown  spots  resembling  moles,  but  not  raised.  Moisture  of 
the  skin  with  clamminess  is  common.  It  is  limited  to  the  palms  of 
the  hands,  or  may  occur  in  the  distribution  of  certain  nerves.  The 
sweats  are  not  acid;  they  are  usually  local,  but  may  be  profuse.  Pain 
independent  of  the  joint-lesion  is  due  to  neuritis,  and  may  precede  the 


758  SPECIAL  DIAGNOSIS. 

joint-trouble.  It  is  not  merely  confined  to  the  nerve-trunks,  but  affects 
the  smaller  branches  which  are  distributed  to  muscles,  as  the  base  of 
the  thumb.     Numbness  and  tingling  are  often  present.  :;..:;  J, 

The  progress  of  the  disease  is  pretty  steadily  worse.  In  extreme 
cases  not  only  are  the  limbs  crippled,  deformed,  and  helpless,  but  there 
is  fixation  of  the  cervical  spine  and  of  the  articulations  of  the  jaw,  so 
that  the  patient  cannot  move  the  head  or  masticate  food. 

The  following  describes  the  characteristic  deformity  of  the  hand: 
The  first  phalanx  of  the  fingers  is  either  flexed  upon  the  metacarpus  or 
extended,  and  the  terminal  phalanx  in  like  manner  is  either  markedly 
flexed  or  extended  upon  the  second,  or  these  two  phalanges  are  kept  at 
a  straight  line,  while  the  first  phalanx  is,  as  usual,  decidedly  flexed  upon 
the  metacarpus.  The  hand  is  pronated  and  the  fingers  turn  toward 
the  ulnar  side  (Palmer  Howard,  and  Charcot).    (See  page  131,  Fig.  13.) 

The  foot  is  abducted  and  flattened,  and  the  great  toe  abducted  across 
and  above  the  other  toes.  Rarely  it  may  be  beneath  the  other  toes. 
The  metatarso-phalangeal  joint  is  enlarged. 

A  variety  of  the  disease  is  sometimes  met  with,  chiefly  in  old  per- 
sons (senile  arthritis),  in  which  the  tendency  is  to  involve  one  or  two 
joints,  particularly  the  hip,  or  hip  and  knee.  It  is  of  slow  progress 
and  is  otherwise  attended  with  the  same  deformities  as  the  usual  poly- 
articular form. 

Rheumatoid  arthritis  is  distinguished  from  gout  by  the  abseuce  of 
heredity  and  by  its  development  under  the  exhausting  influences  of 
repeated  pregnancies,  lactation,  poverty,  and  malnutrition.  Rheuma- 
toid arthritis  is  progressive,  with  occasional  remissions;  gout  occurs  in 
successive  attacks,  with  intermissions.  Uric  acid  is  absent  from  the 
blood  in  the  former  and  is  present  in  gout.  Rheumatoid  arthritis  in 
the  vast  majority  of  cases  is  subacute  or  chronic.  The  acute  form  is 
distinguished  from  acute  gout  by  the  duration  of  the  paroxysm  and  the 
absence  of  intermissions  ;  by  there  being  less  heat,  swelling,  and  red- 
ness of  the  joints,  and  less  infiltration  of  the  soft  parts;  by  the  fact 
that  large  and  small  joints  are  involved,  and  that  there  is  no  special 
tendency  to  inflammation  of  the  great  toe. 

From  chronic  gout  rheumatoid  arthritis  is  distinguished  by  the  ab- 
sence of  hereditary  predisposition,  of  repeated  acute  attacks,  and  of  the 
causes  of  gouty  paroxysms — indulgence  in  sugars,  acids,  malt  liquors, 
etc.  Moreover,  rheumatoid  arthritis  most  frequently  begins  in  the 
hands,  and  is  symmetrical  and  bilateral.  Gout  has  a  predilection  for 
the  great  toe,  and  is  unilateral.  Again,  gout  attacks  well-fed  males 
most  frequently  after  the  age  of  thirty  years,  while  rheumatoid  arth- 
ritis tends  to  attack  women  under  the  depressing  influences  already 
mentioned.  It  may,  however,  occur  in  both  sexes,  and  even  be  asso- 
ciated with  gout. 

Rheumatic  fever  is  distinguished  from  acute  rheumatoid  arthritis  by 
its  tendency  to  involve  the  larger  joints,  its  erratic  course,  acid  sweats, 
and  heavy  deposits  of  urates  from  the  urine,  its  shorter  course,  its 
tendency  to  heart-complications,  and  its  subsidence  without  impairment 
of  the  usefulness  of  the  joiuts. 

Chronic  articular  rheumatism  is  distinguished  by  the  preceding  history, 


CONSTITUTIONAL  DISEASES.  759 

the  tendency  to  seasonal  exacerbations,  by  its  involving  fewer  joints,  and 
not  being  so  symmetrical  in  the  joints  affected.  It  does  not  produce 
so  great  deformity  as  is  common  in  rheumatoid  arthritis,  nor  is  it  so 
likely  to  affect  the  vertebrae  and  jaws.  The  existence  of  valvular 
heart  disease  or  a  history  of  antecedent  chorea  is  in  favor  of  rheuma- 
tism. 

The  joint-affections  of  locomotor  ataxia  are  distinguished  by  the  asso- 
ciated symptoms  of  incoordination  and  absent  knee-jerk,  by  their  sud- 
den onset  without  pain  or  fever,  by  the  occurrence  of  large  effusion 
into  the  joint  with  subsequent  disorganization,  fractures,  and  disloca- 
tions. 

Gonorrhosal  arthritis  is  distinguished  by  the  history  of  gonorrhoea  or 
the  existence  of  a  discharge  from  the  urethra,  by  the  tendency  of  the 
disease  to  attack  the  larger  joints,  particularly  the  knee  or  shoulder, 
and  to  become  fixed  in  one,  not  wandering  from  one  to  another.  The 
affected  joint  suffers  effusion,  and  the  synovial  membranes  and  bursse 
are  inflamed.  The  process  is  very  chronic,  but  indolent,  and  the  heart 
rarely  becomes  affected. 

Gout. 

A  disease  characterized  by  specific  arthritis,  associated  with  uric  acid 
in  the  blood  and  the  deposit  of  sodium  urate  in  the  joints,  or  mani- 
festing itself  as  a  diathesis  in  which  occur  other  inflammations  of  non- 
articular  tissues  and  various  disturbances  of  functions  of  organs,  the 
blood  also  containing  uric  acid. 

Gout  is  common  in  Europe,  particularly  in  England,  but  in  its  artic- 
ular form  is  rare  in  this  country.  There  is  an  hereditary  predisposition 
in  from  50  to  60  per  cent,  of  the  cases.  It  results  from  overeating  of 
rich  foods  and  the  drinking  of  malt  liquors,  associated  with  insufficient 
exercise  and  excretion.  Garrod  has  called  attention  to  its  association 
with  lead-poisoning.  Paroxysms  are  induced  by  indiscretions  in  eating 
or  drinking,  by  nervous  shock  or  great  mental  strain,  by  exposure  to 
cold  or  injury,  or  by  overwork  and  sexual  excesses. 

The  characteristic  phenomena  of  gout  are  preceded  for  a  variable  time 
by  acid  flatulent  dyspepsia,  colicky  pains  in  the  stomach  and  bowel, 
constipation  alternating  with  diarrhoea,  and  scauty,  heavily  loaded 
urine.  Accompanying  these  dyspeptic  symptoms  often  are  impairment 
of  physical  and  mental  vigor,  irritability  of  temper,  and  hypochon- 
driasis. 

In  other  cases  the  premonitory  symptoms  are  palpitation  of  the 
heart,  or  dyspnoea  resembling  asthma,  or  various  nervous  symptoms, 
as  drowsiness,  insomnia,  or  headache. 

In  acute  articular  gout  the  onset  is  often  sudden,  especially  in  the 
l'n-t  attack.  The  patient  may  go  to  bed  in  apparent  health,  but  wake 
up  early  in  the  morning  with  a  feeling  of  discomfort  or  uneasiness, 
usually  in  the  great  toe.  In  some  cases  the  pain  is  agonizing  from  the 
first.  The  patient  finds  he  is  unable  to  step  upon  the  foot  without 
torturing  pain.  The  ball  of  the  great  toe  is  hot,  swollen,  red,  and 
exquisitely  resentful  of  the  slightest  touch  or  jar  of  the  bed.  The 
veins  are  swollen  and  the  joint  stiff.     There  is  slight  fever,  perhaps 


760  SPECIAL  DIAGNOSIS. 

chilliness,  thirst,  coated  tongue,  constipation,  scanty,  high-colored  urine 
depositing  urates  on  cooling;  the  skin  is  warmer  than  normal  and  there 
is  slight  perspiration.  The  pain  usually  abates  during  the  day  and 
increases  at  night.  It  is  aggravated  by  motion  and  attended  by  pain- 
ful muscular  cramps.  By  the  end  of  the  first  day  or  two  the  swelling 
increases  and  the  pain  lessens,  owing  to  diminished  tension  of  the  part. 
Pain  on  motion  is  still  great,  however,  and  without  treatment  may 
continue  for  a  week  or  two;  under  treatment  the  paroxysm  subsides  in 
four  or  five  days. 

Both  great  toes  may  be  attacked  in  the  first  seizure,  more  often  alter- 
nately than  simultaneously,  and  sometimes  other  joints  than  that  of 
the  toes  are  affected. 

After  the  subsidence  of  an  attack  the  urine  contains  a  larger  quan- 
tity of  uric  acid,  and  the  patient  feels  better  in  health  and  spirits  than 
for  some  time.  A  second  attack  may  be  postponed  for  several  years, 
but  usually  after  that  the  intervals  between  them  steadily  diminish, 
until  an  attack  recurs  every  few  weeks  or  months,  and  the  patient 
may  be  scarcely  ever  free  from  it.  Other  joints  than  the  toes,  partic- 
ularly those  of  the  fingers,  become  involved  in  subsequent  attacks. 

The  blood.  Neusser  has  attributed  to  gout  and  the  uric  acid  diath- 
esis the  presence  of  granules,  observed  after  staining,  in  the  white 
corpuscles,  but  they  have  been  found  in  other  affections.     (See  Blood.) 

Chronic  gout  results  from  repeated  acute  attacks.  It  is  characterized 
by  deformity  of  the  affected  joints,  around  which  are  deposited  chalk- 
stones  (tophi)  of  sodium  urate.  Similar  deposits  occur  in  the  helix 
of  the  ear.  The  first  appearance  is  that  of  a  clear  vesicle  under  the 
skin,  which  subsequently  becomes  chalky-white  and  solid.  The  deposits 
of  sodium  urate  occur  not  only  in  the  cartilages  of  the  joints,  but  in 
the  ligaments  and  bursse  also,  resulting  in  great  impairment  of  motion 
and  deformity.  "  In  extreme  cases  an  appearance  is  presented  by  the 
hand  very  closely  resembling  a  bundle  of  French  carrots  writh  their 
heads  forward,  the  nails  appearing  to  take  the  place  of  the  stalks  " 
(Garrod). 

Gouty  abscesses  consist  of  collections  of  liquid  and  solid  sodium 
urate,  which  discharge,  with  or  without  pus,  through  the  skin.  A 
patient  may  have  a  number  of  them  with  but  very  little  impairment 
of  the  general  health.  They  may  even  act  as  a  helpful  vent  to  the 
system. 

In  so-called  retrocedent  gout  the  external  joint-manifestation  is  sup- 
pressed or  replaced  by  an  internal  inflammation,  as  of  one  of  the  serous 
membranes. 

Gout  attacks  the  nervous  system,  causing  headache,  delirium,  and 
sometimes  apoplexy,  apoplectiform  seizures,  epilepsy,  mania,  various 
neuralgias,  and  spinal  symptoms. 

It  also  affects  the  heart  and  bloodvessels,  causing  valvulitis  and  chronic 
arteritis. 

The  symptoms  presented  by  the  digestive  organs  have  been  mentioned. 
They  are  often  premonitory  of  an  attack. 

The  kidneys  may  be  affected,  causing  typical  contracted  kidney,  or 
there  may  be  chronic  cystitis  and  urethritis. 


CONSTITUTIONAL  DISEASES.  761 

The  skin  gives  evidence  of  its  presence  particularly  in  the  form  of 
psoriasis  and  eczema. 

Rhachitis. 

Rhachitis  is  a  constitutional  affection  characterized  by  changes  in  the 
bones  which  lead  to  permanent  alteration  in  their  shape.  It  is  usually 
developed  in  childhood,  and  is  most  common  in  children  with  bad  hygi- 
enic surroundings,  who  have  lived  upon  a  starchy  diet  and  have  taken 
cow's  milk  for  too  long  a  period  of  time.  A  child  that  has  been  nursed 
during  the  mother's  pregnancy  is  liable  to  have  the  disease. 

The  appearance  of  the  face  and  the  changes  in  the  bones  have  been 
previously  described  (see  page  121). 

In  addition  to  changes  in  the  bones  a  child  presents  other  evidences 
of  defective  nutrition.  There  is  marked  pallor;  the  muscles  are  flabby; 
the  child  is  feeble;  and  the  weakness  of  the  muscles  results  in  an  inac- 
tion which  resembles  paralysis. 

The  disease  usually  progresses  slowly,  and  is  eminently  chronic. 
A  form  is  seen,  however,  in  which  the  progress  of  the  symptoms  is 
more  acute.  With  some  gastro-intestinal  disturbances  there  are  mild 
fever,  considerable  weakness,  and  great  restlessness.  Sleep  is  disturbed, 
and  pain  is  complaiued  of  if  the  child  is  of  an  age  to  make  such  com- 
plaint. Soreness  of  the  body  is  observed  on  handling  the  child;  and  of 
its  own  accord,  on  account  of  the  pain  and  soreness,  it  avoids  all  cus- 
tomary movements.  The  child  lies  on  its  back  and  shrinks  from  any 
attempts  to  disturb  it.  The  pain  is  not  only  caused  by  handling  of 
the  muscles,  but  the  bones  also  are  sore  and  tender.  Sometimes  the 
most  marked  manifestations  of  the  more  acute  forms  are  the  gastro- 
intestinal symptoms.  It  may  often  happen  that  vomiting  and  diar- 
rhoea have  as  an  underlying  basis  this  rhachitic  condition. 

With  the  above  symptoms,  and  also  in  chronic  cases,  perspirations 
about  the  head  are  common.  There  is  usually  more  heat  of  the  head 
than  is  natural,  hence  in  sleep  the  child  rolls  the  head.  This  rolling 
causes  the  hair  on  the  back  of  the  head  to  be  worn  off.  This  sign  is 
most  characteristic  of  rhachitis  when  observed  along  with  changes  in 
the  skeleton. 

In  the  acute  and  chronic  forms  enlargement  of  the  liver  and  spleen 
is  observed.  The  enlargement  is  not  only  actual,  but  also  a  false 
enlargement  may  be  seen  from  distortion  of  the  organs  on  account  of 
changes  in  the  vertebrae  and  ribs.  The  abdomen  is  prominent,  usually 
on  account  of  flatulency,  although  the  enlarged  organs  contribute  to 
the  swelling. 

Nervous  phenomena  are  common  in  the  course  of  rhachitis.  Tetany 
limited  to  the  upper  extremities,  and  laryngismus  stridulus  are  the  most 
frequent.  Either  of  these  complications  may  occur  before  the  disease 
is  otherwise  suspected. 

Diagnosis.  The  possible  presence  of  rhachitis  must  not  be  over- 
looked in  cases  of  chronic  vomiting  in  childhood.  The  acute  form 
of  the  disease  must  not  be  confounded  with  scurvy,  as  often  happens 
in  the  case  of  children.  It  must  not  be  forgotten  that  scurvy  may 
set  in  in  the  course  of  rhachitis.     In  scurvy  the  pain,  tenderness, 


762  SPECIAL  DIAGNOSIS. 

and  weakness  are  limited  to  the  lower  extremities.  The  immobility 
of  the  extremities  may  go  on  to  pseudoparalysis.  The  tenderness, 
however,  is  great;  oedema  is  more  pronounced,  and  local  areas  of 
periostitis  are  more  common.  In  scurvy  the  gums  are  swollen  and 
may  be  spongy,  or  may  be  the  seat  of  ecchymoses.  The  most  decisive 
diagnostic  criterion  is  the  therapeutic  test,  scurvy  rapidly  yielding  to 
a  proper  regimen. 

Scurvy. 

Scorbutus,  or  scurvy,  is  a  constitutional  condition  brought  about  by 
a  long-continued  diet  deficient  in  fresh  vegetables.  It  is  characterized 
by  pallor,  great  physical  weakness  and  mental  sluggishness,  dyspnoea, 
subcutaneous  and  submucous  hemorrhages,  a  swollen,  spongy  condition 
of  the  gums,  and  a  brawny  induration,  especially  of  the  calves  and 
hams. 

The  onset  of  the  disease  is  gradual,  and  is  marked  by  a  peculiar 
dirty-yellow  or  greenish  pallor  of  the  face,  associated  soon  with  an 
apathetic  expression  of  the  face,  physical  tveahness,  and  decided  lack  of 
customary  energy.  The  appearance  is  so  characteristic  that  patients 
are  said  readily  to  detect  it  in  others,  though  unaware  of  it  themselves. 
Sleep  and  digestion  are  good,  but  rheumatoid  pains  may  be  complained 
of.  Other  prominent  subjective  symptoms  are  fatigue  on  slight  exer- 
tion, dyspnoea,  faintness,  and  despondency.  In  the  course  of  a  week 
or  two  petechias  appear  upon  the  lower  extremities,  especially  around 
a  hair  as  the  centre  (see  page  76).  Depending  upon  the  severity  of  the 
case  there  are  also  bullae,  vibices,  and  ecchymoses.  Brawny  induration, 
due  to  deep  effusion  of  blood,  occurs  especially  in  the  calves  and  hams, 
producing  considerable  pain  on  flexure  of  the  knees. 

There  is  no  fever  apart  from  complications.  The  pulse  is  frequent, 
weak,  and  small,  and  the  first  sound  of  the  heart,  and  the  impulse, 
may  be  very  faint. 

The  face  is  swollen  and  of  a  dirty,  possibly  greenish-yellow  color, 
according  to  Bird,  Buzzard,  and  others;  in  some  cases  the  eye  and  its 
surroundings  are  the  only  parts  exhibiting  signs  of  scurvy  at  this  time. 
"  The  integument  around  one  or  both  orbits  is  puffed  up  into  a  bruise- 
colored  swelling.  The  conjunctiva?  covering  the  sclerotic  is  tumid  and 
of  a  brilliant  red  color  throughout,  and  about  an  eighth  of  an  inch  in 
thickness  or  elevation  above  the  cornea,  leaving  the  cornea  at  the  bot- 
tom of  a  circular  trench  or  well."1  The  condition  is  not  inflammatory. 
These  cases  often  terminate  fatally. 

Almost  always  the  sums  swell,  become  spongy,  and  bleed  upon  the 
slightest  irritation.  They  are  dark  cherry-red  in  color  and  look  not 
unlike  a  split  cherry.  Sometimes  they  swell  so  as  almost  to  hide  the 
teeth  completely,  and  even  to  protrude  the  lips.  The  breath  has  a 
heavy,  sickening  odor,  and  the  teeth  sometimes  drop  out  of  their 
sockets. 

In  addition  to  the  cutaneous  and  gingival  hemorrhages,  hemorrhages 
occur  from  the  nose  and  other  mucous  surfaces,  and  effusions  take 

1  Buzzard  :  Reynolds'  System  of  Medicine,  1880,  vol.  i.  p.  451. 


CONSTITUTIONAL  DISEASES.  763 

place  into  the  lungs,  intestines,  pericardium,  and  pleura,  associated 
with  inflammatory  products.  There  may  be  no  physical  signs  on  the 
part  of  the  lungs  to  account  for  the  dyspnoea,  or  some  dulness  and 
bronchial  breathing,  or  a  few  rales,  may  be  detected. 

A  very  peculiar  symptom,  and  sometimes  the  earliest,  is  hemeral- 
opia,  nyctalopia,  or  night-blindness,  in  which  the  patient  can  see 
during  the  day,  but  not  by  moonlight,  and  apart  from  artificial  light 
is  totally  blind  at  night. 

So-called  scurvy -rickets  is  more  or  less  common  in  infants  fed  on 
artificial  food  exclusively,  or  on  sterilized  milk.  It  is  therefore  limited 
to  the  first  four  or  five  years.  The  symptoms  of  scurvy  are  added  to 
those  of  rhachitis.  In  the  eight  cases  1  have  seen,  the  most  pronounced 
features  were  those  of  weakness,  anaemia,  polyuria,  restlessness,  the 
scorbutic  gums,  local  periostitis,  particularly  of  the  tibia,  sometimes 
periarticular  inflammation,  and  always  a  general  tenderness  of  the 
body,  as  in  rhachitis. 

Diabetes  Mellitus. 

The  occurrence  of  any  of  the  following  conditions  should  lead  to  an 
examination  of  the  urine  for  sugar,  and  an  estimation  of  the  quantity 
of  urine  passed  in  twenty-four  hours,  apart  from  the  routine  examina- 
tion, which  should  be  made  in  every  case  of  chronic  disease  or  of  obscure 
acute  disease.  1.  Muscular  weakness  without  cause.  The  weakness 
is  progressive  and  rapidly  advances  to  an  extreme  degree.  2.  Emaci- 
ation. In  young  subjects  this  is  rapid  in  cases  of  diabetes.  In  older 
patients  it  is  not  so  striking,  particularly  if  the  gouty  diathesis  is  pres- 
ent. 3.  Thirst.  This  is  a  symptom  which  is  of  common  occurrence 
in  diabetes,  and  is  most  distressing.  If  the  amount  of  fluids  taken  be 
compared  with  the  amount  of  urine  excreted,  it  will  be  found  that  the 
two  bear  a  definite  ratio.  The  thirst  is  greater  immediately  after 
meals,  although  the  patient  does  not  necessarily  have  indigestion.  4. 
Hunger.  Excess  of  appetite,  boulimia  or  polyphagia,  also  occurs  in 
diabetes.  The  amount  of  food  that  is  taken  is  sometimes  enormous, 
and  the  ravenous  way  it  is  devoured  is  revolting.  5.  Loss  of  sexual 
power. 

The  five  symptoms  just  mentioned,  with  increased  frequency  in  mic- 
turition, are  the  common  symptoms  of  diabetes  mellitus.  They  may 
develop  gradually.  In  rare  instances  the  onset  is  sudden.  The  occur- 
rence of  these  symptoms  should  lead  at  onCe  to  an  examination  of  the 
renal  secretion. 

Three  special  characteristics  of  the  urine  are  observed.  A.  The 
amount  is  increased  so  that  from  six  to  ten  pints,  or  even  as  much  as 
thirty  to  forty  pints,  are  passed  in  twenty-four  hours.  B.  The  specific 
gravity  ranges  from  1025  to  1045,  and  may  eveo  be  higher.  C.  The 
presence  of  sugar.  The  sugar  is  detected  by  the  ordinary  tests  (see 
Examination  of  Urine).  In  addition  the  urine  is  usually  of  pale  color, 
of  a  sweetish  odor  and  acid  reaction. 

In  addition  to  thirst  and  increased  appetite,  some  gastro-intestinal 
symptoms  may  be  of  diagnostic  importance.  Of  these,  first,  the  ap- 
pearance of  the  tongue  is  characteristic.     It  is  dry,  red,  and  glazed. 


764  SPECIAL   DIAGNOSIS. 

The  dryness  is  increased  because  of  the  scanty  flow  of  saliva.  The 
gums  are  swollen  and  spongy,  and  marginal  gingivitis  and  stomatitis  are 
often  present.  There  are  no  marked  dyspeptic  symptoms.  Constipa- 
tion is  of  common  occurrence. 

In  diabetes  other  secretions  diminish.  Perspirations  do  not  occur, 
except  in  inflammatory  complications.  The  skin  is  harsh  and  dry. 
As  the  disease  progresses  the  heart's  action  becomes  weak  and  the  pulse 
frequent,  with  lowered  tension.  The  temperature  of  the  body  is  usually 
below  normal. 

Diabetes  may  occur  at  any  age,  but  is  most  frequent  in  adult  life. 
In  young  adults  the  symptoms  are  more  pronounced,  and  the  duration 
shorter.  Iu  patients  past  middle  life  the  disease  may  continue  for  a 
long  period  of  years  without  marked  interference  with  the  health  and 
nutrition. 

While  the  symptoms  just  mentioned  should  lead  to  an  examination 
of  the  urine,  diabetes  mellitus  may  not  be  suspected  by  any  of  the 
usual  objective  or  subjective  symptoms.  It  may  happen  that  none  of 
these  symptoms  is  sufficiently  marked,  and  that  only  by  routine  exam- 
ination of  the  urine,  or  by  the  occurrence  of  affections  known  to  be 
associated  with  sugar  in  the  urine,  is  the  disease  discovered. 

Of  the  complications  which  should  lead  to  the  suspicion  of  sugar  in 
the  urine  the  following  are  the  most  important: 

1.  Cutaneous  Complications.  Boils  and  carbuncles  should  always 
lead  to  an  examination  of  the  urine.  Pruritus  and  chronic  eczema  may 
have  diabetes  in  the  background.  Gangrene  of  the  extremities,  chiefly 
of  the  feet  and  legs,  and  gangrene  in  other  situations,  is  of  common 
occurrence  in  the  course  of  diabetes. 

2.  Lung-complications.  Tuberculosis,  both  of  the  chronic  and  the 
acute  pneumonic  type,  is  frequently  associated  with  diabetes.  Lobar 
pneumonia  is  apt  to  occur.  In  all  cases  of  pneumonia  the  urine  should 
be  examined  for  sugar.  Its  presence  would  modify  the  prognosis  of 
an  otherwise  moderate  case.  Gangrene  is  likely  to  ensue  in  the  acute 
and  chronic  lung  affections.  Gangrene  of  the  lung  in  the  course  of 
diabetes  may  be  latent  and  recognized  only  by  the  odor  and  the  character 
of  the  expectoration,  or  it  may  run  an  acute  febrile  course. 

3.  Nervous  Symptoms.  Diabetic  coma  may  develop  in  the  course  of 
the  disease.  In  young  subjects,  particularly,  the  occurrence  of  coma 
should  lead  to  a  suspicion  of  diabetes.  Such  coma  may  occur  before 
the  disease  has  been  recognized.  The  coma  may  follow  an  attack  of 
fainting  and  prostration,  with  stupor,  which  deepens  into  complete 
unconsciousness.  It  may  be  preceded  by  nausea  and  vomiting  or  by 
the  lung-complications  previously  mentioned.  This  form  of  coma  is 
usually  associated  with  extreme  dyspnoea,  and  attended  by  agitation, 
pain  in  the  head,  and  some  delirium.  .  The  pulse  becomes  rapid  and 
feeble,  and  coma  develops  gradually.  For  this  form  of  coma  the  term 
acetoncemia  is  used.  The  breath  is  of  a  peculiar  sweetish  odor,  due  to 
acetone,  and  this  compound  is  detected  iu  the  urine.  Coma  may  occur 
without  any  premonitory  symptoms  whatsoever,  the  patient  reeling  for 
a  short  time,  and  complaining  of  pain  in  the  head  as  if  intoxicated. 

Peripheral  neuritis  should  always  lead  to  an  examination  of  the  urine. 


CONSTITUTIONAL  DISEASES.  7(j5 

It  may  be  limited  to  one  group  of  nerves,  or  may  be  more  or  less  gen- 
eral with  symptoms  like  those  of  locomotor  ataxia,  as  the  lightning- 
pains,  abolition  of  reflexes  and  loss  of  power  in  the  extensor  muscles. 
Diabetic  patients  are  also  subject  to  neuralgia,  and  to  peripheral  hyper- 
esthesia and  paresthesia,  probably  due  to  neuritis.  The  neuritis  may 
be  so  extreme  as  to  lead  to  paraplegia. 

4.  Eye-symptoms.  A  curious  symptom  of  diabetes  is  the  occurrence 
of  cataract.  This  may  develop  at  any  age,  and  is  often  rapid  in  its 
course.  Cataract  or  alterations  of  vision  should  always  demand  an 
examination  of  the  urine.  Diabetic  retinitis  is  sometimes  present. 
Atrophy  of  the  optic  nerves,  or  muscular  insufficiencies,  may  take 
place,  the  latter  causing  the  pronounced  symptoms  of  eye-strain. 
Ringing  in  the  ears,  deafness,  the  occurrence  of  acute  otitis,  are  phe- 
nomena which  arise  in  the  course  of  diabetes. 

Diagnosis.  Sugar  in  the  urine  occurs  temporarily  when  there  is 
an  excess  of  saccharine  diet,  or  when  there  is  functional  disorder  of 
the  liver.  The  sugar  is  small  in  amount,  and  the  glycosuria  is  tran- 
sient. The  diagnosis  of  true  diabetes  is  not  difficult,  although  the 
disease  may  be  overlooked  unless  the  habit,  previously  insisted  upon, 
of  constant  urinary  examinations  is  fully  developed. 

Diabetes  Insipidus. 

This  form  of  diabetes  differs  from  the  preceding  in  that  the  large 
amount  of  urine  is  normal,  but  of  low  specific  gravity.  The  disease 
may  come  on  suddenly  after  mental  emotion,  or  develop  gradually. 
The  amount  of  urine  may  range  from  ten  to  forty  pints.  The  urine 
is  of  low  specific  gravity — from  1001  to  1005.  It  is  pale  and  watery. 
The  solid  constituents  are  not  reduced.  Urea  is  sometimes  increased, 
but  abnormal  constituents  are  very  rare.  The  passage  of  large  amounts 
of  urine  induces  thirst,  but  otherwise  the  symptoms  do  not  tally  with  the 
symptoms  of  diabetes  mellitus.    The  patients  are  usually  well  nourished. 

The  disease  is  usually  secondary  to  some  organic  disease  of  the  brain, 
or  of  the  abdomen,  as  tubercular  peritonitis,  abdominal  tumors,  or 
aneurisms.  It  usually  occurs  in  males,  and  is  often  hereditary.  It  is 
most  common  in  young  people.  Traumatism,  meningitis,  affections  of 
the  brain  involving  the  sixth  nerve,  tumors  of  the  brain  or  of  the 
medulla,  are  causal  factors.  It  may  follow  fright,  a  protracted  debauch, 
or  perturbation  of  the  nervous  system  from  other  causes. 

The  diagnosis  is  not  difficult.  It  must  be  distinguished  from  the 
polyuria  that  is  seen  in  chronic  interstitial  nephritis,  and  in  amyloid 
disease.  In  hysteria,  polyuria  is  common,  although  transitory.  The 
presence  of  the  stigmata  and  other  hysterical  manifestations  lead  to 
the  diagnosis  in  hysteria. 

Haemophilia.' 

Hemophilia  is  a  constitutional  affection  characterized  by  bleeding, 
which  is  spontaneous  or  occurs  upon  slight  injury.  It  is  nearly  always 
hereditary,  but  may  arise  de  novo. 

1  See  Hemorrhages,  p.  75. 


766  SPECIAL  DIAGNOSIS. 

Males  are  very  much  more  liable  to  it  than  females,  the  ratio  being 
about  11  to  1.  This  curious  disposition  to  bleeding  may  be  transmitted 
for  generations,  and  almost  always  to  the  males  through  the  female 
members  of  the  family — that  is  to  say,  the  daughter  of  a  bleeder  is 
not  usually  affected,  but  she  transmits  the  tendency  to  her  sons,  who 
become  bleeders;  so  too  the  granddaughters  are  not  bleeders,  but  they 
in  turn  transmit  the  disposition  to  their  male  offspring.  It  generally 
shows  itself  early  in  life,  usually  before  the  end  of  the  second  year, 
and  almost  invariably  by  puberty. 

The  affection  usually  first  declares  itself  by  the  occurrence  of  a  hem- 
orrhage, either  spontaneous  or  the  result  of  slight  injury,  the  bleeding 
being  far  more  profuse  than  would  be  natural,  and  in  some  cases  abso- 
lutely uncontrollable. 

Legg1  has  divided  .haemophilia  into  three  degrees,  according  to  the 
severity  of  the  symptoms.  The  first  is  characterized  by  external  and 
internal  bleedings  of  every  kind,  and  by  joint-affections;  the  second, 
by  spontaneous  hemorrhages  from  mucous  membranes,  but  no  traumatic 
bleeding  or  ecchymoses,  and  no  joint-affections ;  the  third,  by  a  ten- 
dency simply  to  ecchymoses.  The  first  form  is  seen  most  frequently  in 
men  ;  the  second  most  frequently  in  women;  and  the  third  in  either  sex. 

The  most  frequent  seat  of  hemorrhage  is  the  nose,  and  the  next  the 
gastro-intestinal  tract.  The  bleeding  is  from  the  capillaries;  it  may 
prove  fatal  in  a  few  hours,  or  last  for  days  and  weeks  with  final  recov- 
ery. Intense  anaemia  follows  the  prolonged  hemorrhage,  but  the  blood 
is  replaced  with  remarkable  rapidity.  All  operations,  even  the  most 
trivial,  are  extremely  dangerous  in  bleeders.  Circumcision,  extraction 
of  teeth,  and  leeching  are  credited  with  the  most  deaths  by  Grandidier. 

Joint-symptoms  are  very  common.  The  knees,  elbows,  ankles,  and 
shoulders  are  the  ones  most  frequently  involved.  The  attack  may  be 
marked  by  pain,  redness,  swelling,  inflammation,  and  fever;  or  fever 
may  be  absent ;  or  pain  alone  may  be  complained  of.  The  attacks  are 
liable  to  recur,  especially  in  cold,  damp  weather,  and  may  result  in 
stiffened,  deformed  joints. 

The  diagnosis  (see  page  77)  is  easy  when  the  history  of  an  hereditary 
tendency  to  bleed  can  be  obtained.  Osier2  properly  remarks  that  slight 
joint-trouble  and  petechia?  are  as  much  a  manifestation  of  the  disease 
as  the  more  severe  hemorrhages.  In  cases  in  which  no  history  can  be 
got  the  diagnosis  is  made  by  noting  a  persistent  liability  to  hemorrhage, 
without  adequate  cause,  and  associated  with  joint-affections. 

Osier  gives  the  following  excellent  summary  of  the  affections  with 
which  haemophilia  can  be  confounded: 

1.  The  umbilical  hemorrhages  of  infants,  due  to  jaundice  or  to  syph- 
ilis hsemorrhagica  neonatorum,  etc. 

2.  Purpura  simplex,  often  seen  in  debilitated,  rarely  in  healthy  chil- 
dren, usually  confined  to  the  legs,  and  in  some  cases  associated  with 
rheumatic  pains  or  swellings  in  the  knees  and  ankles. 

3.  Peliosis  rheumatica. 

4.  Purpura  hemorrhagica,  morbus  maculosus  Werlhofii,  a  grave 
disease,  characterized  by  extensive  cutaneous  ecchymoses,  mucous  heni- 

1  Haemophilia.    London,  1892. 

a  Quoted  by  Osier,  Pepper's  System  of  Medicine,  1885,  iii.  932. 


CONSTITUTIONAL  DISEASES.  767 

orrhages,  but  not  dependent  on  any  local  disease,  or,  as  far  as  known, 
on  any  specific  poison. 

5.  Infective  purpura  due  to  the  action  of  some  specific  poison — small- 
pox, measles,  scarlet  fever,  cerebro-spinal  fever,  etc.  The  hemorrhages 
may  be  cutaneous  and  trivial,  or  may  be  in  the  most  aggravated  form 
of  interstitial  and  mucous  bleedings,  as  seen,  for  example,  in  black 
smallpox. 

6.  Toxic  purpura,  as  in  snake-bites  and  many  poisons,  such  as  phos- 
phorus. 

7.  Simple  hemorrhagic  diathesis,  under  which  may  be  included  those 
cases  in  which,  without  any  hereditary  disposition  or  previous  hemor- 
rhagic history,  there  is  a  tendency  to  uncontrollable  hemorrhage  from 
a  slight  wound. 

8.  Hsematidrosis,  bloody  sweats,  which  occur  usually  in  hysterical 
or  epileptic  females,  and  are  in  rare  instances  accompanied  by  mucous 
hemorrhages. 

Purpura. 

Secondary  purpura  occurs  in  connection  with  a  variety  of  febrile  and 
constitutional  diseases:  1.  Scurvy.  2.  Haemophilia.  3.  Hodgkin's 
disease.  4.  Splenic  leucocythsemia.  5.  Pernicious  anaemia.  6. 
Chronic  lesions  of  the  kidney  and  liver.  7.  Ulcerative  endocarditis. 
8.   Malignant  sarcomata. 

Primary  purpura  occurs  without  any  known  cause.  It  has  been 
divided  for  convenience  into  simple  and  hemorrhagic  purpura,  though 
the  two  probably  differ  only  in  intensity. 

1.  In  simple  purpura  the  hemorrhages  are  limited  to  the  skin  (see 
page  77).  They  consist  of:  1.  Bright-red  spots,  varying  in  size  from 
a  pin-head  to  a  silver  three-cent  piece.  These  spots  are  under  the 
skin  and  are  unaffected  by  pressure.  They  fade  gradually  from  red 
to  yellow  and  disappear.  2.  Larger  spots  or  streaks  called  vibices. 
3.  Erchymoses. 

The  disease  is  said  to  be  most  common  about  the  age  of  puberty. 
It  may  come  on  in  the  midst  of  apparent  health,  or  it  may  follow  an 
illness,  as  typhoid  fever. 

Purpura  occurs  especially  upon  the  legs,  the  standing  position  seem- 
ing to  favor  its  occurrence.  It  comes  on  in  successive  crops.  Some- 
times large  blebs  filled  with  thin  blood  form  under  the  skin,  and 
gangrene  at  times  occurs. 

2.  In  the  hemorrhagic  form1  hemorrhages  occur  from  the  nose,  stom- 
ach, bowels,  vagina,  and  bronchi,  or  into  the  kidney  or  other  viscus. 
Cutaneous  and  submucous  hemorrhages  also  occur. 

The  onset  of  these  cases  is  sudden,  though  there  may  be  a  day  or  two 
of  depression,  lassitude,  headache,  and  nausea.  The  first  symptom 
noticed  is  generally  fever,  which  is  apt  to  be  moderate,  then  the  erup- 
tion upon  the  skin  is  detected,  and  for  a  day  or  two  the  patienl  may 
seem  to  be  only  slightly  ailing.  Copious  epistaxis  may  now  occur,  or 
a  hsematemesis  or  hsematuria,  or  all  of  these  mid  other  hemorrhages 
may  occur  the  same  day.     The  temperature  may  be  only  moderately 

1  See  "  Grave  Forms  of  Purpura  Hemorrhagica."    Musser :  Trans.  Association  of  American  Phy- 
sicians, vol.  vi. 


768  SPECIAL  DIAGNOSIS. 

raised,  or  it  may  reach  104°  to  105°,  or  even  a  higher  point.  The 
pulse  at  first  is  frequent  (120  to  140),  but  of  good  volume  and  tension. 
Subsequently,  in  unfavorable  cases,  it  becomes  thready  and  very  fre- 
quent. Respiration  is  not  affected,  and  the  mind  is  clear;  the  face  is 
pale  and  anxious.  Hemorrhage  may  also  occur  into  the  choroid  and 
brain-substance,  with  blindness  and  paralysis  as  sequels.  It  may  also 
occur  into  the  uvula  or  tonsil. 

The  subjective  symptoms  are  pains  in  the  loins,  limbs,  epigastrium, 
or  chest.  Often  these  pains  announce  a  fresh  hemorrhage,  as  into  the 
kidney,  or  a  fresh  crop  of  purpuric  spots.  The  degree  of  ansemia 
depends  upon  the  copiousness  of  the  hemorrhage  and  the  length  of 
time  the  disease  lasts.  Sometimes  the  hemorrhages  cause  great  exhaus- 
tion, with  a  tendency  to  collapse. 

The  urine,  in  the  case  of  hemorrhage  into  the  kidney,  of  course 
contains  blood;  sometimes  casts  are  also  found. 

3.  Another  variety  of  purpura  is  known  as  peliosis  rheumatica,  the 
peculiar  features  of  which  are  tender  and  swollen  joints,  oedema  of  the 
subcutaneous  cellular  tissue,  and  purpura  associated  with  urticarial 
wheals  and  intense  itching  (purpura  urticans).  The  subcutaneous  hem- 
orrhages consist  of  petechias,  vibices,  and  ecchymoses.  There  may  be 
such  large  hemorrhages  into  the  penis,  scrotum,  and  uvula  as  to  result 
in  gangrene  and  slow  separation  of  the  dead  tissue  by  ulceration.  Epis- 
taxis  may  occur,  but  copious  hemorrhages  from  the  stomach,  the  bowel, 
or  into  the  kidney  or  other  organs  are  rare.  Endocarditis  and  pericar- 
ditis occur  as  complications  in  some  cases.  The  duration  is  apt  to  be 
long,  convalescence  being  delayed  by  repeated  outbreaks  of  purpura 
with  multiple  arthritic  symptoms  and  oedema. 

Diagnosis.  It  is  distinguished  from  scurvy  by  the  absence  of  ante- 
cedent debility  and  anaemia,  of  spongy  gums,  of  brawny  induration  in 
the  limbs,  and  by  the  fact  that  the  hemorrhages  do  not  usually  occur 
around  a  hair- follicle.  In  scurvy  there  is  a  history  of  deprivation  of 
vegetable  food,  whereas  purpura  may  occur  in  the  midst  of  robust 
health.  As  a  rule,  the  cutaneous  hemorrhages  are  larger  in  scurvy 
than  in  purpura. 

It  is  distinguished  from  acute  infectious  diseases,  particularly  typhus, 
cerebro-spinal  fever,  and  smallpox,  by  the  absence  of  severe  constitu- 
tional symptoms  which  characterize  the  graver  forms  of  these  diseases — 
in  which  alone  a  purpuric  eruption  is  likely  to  be  severe  enough  to 
cause  doubt.    Hemorrhages  from  mucous  surfaces  are  rare  in  the  latter. 

Haemophilia  is  distinguished  by  the  history  the  patient  gives  of  being 
a  bleeder  by  heredity,  and  the  fact  that  the  bleeding  has  been  started 
by  some  injury,  wound,  or  operation. 

It  is  distinguished  from  the  hemorrhages  of  leukaemia  by  the  absence 
of  enlarged  spleen  and  liver,  and  by  the  fact  that  there  is  no  excess 
of  leucocytes  in  the  blood. 

Malignant  sarcoma  causing  hemorrhages  is  recognized  by  the  pre- 
vious history  of  ansemia  and  cachexia,  and  by  the  detection  of  primary 
or  secondary  growths. 

It  must  not  be  confounded  with  Raynaud's  disease,  a  vasomotor 
affection  characterized  by  local  syncope,  local  asphyxia,  and  gangrene. 


CHAPTER   X. 

THE  INFECTIOUS  DISEASES. 

The  infectious  diseases  are  those  that  are  produced  by  a  living  con- 
tagion or  micro-organism.  The  organism  is  introduced  into  the  body- 
through  the  skin,  if  the  latter  is  the  seat  of  some  lesion,  as  in  syphilis, 
tuberculosis,  and  anthrax;  through  the  air-passages,  as  in  diphtheria, 
scarlet  fever,  and  other  specific  fevers;  or  through  the  digestive  tract, 
as  in  typhoid  fever,  dysentery,  and  cholera.  The  virus,  as  the  living 
cause  is  named,  iu  many  instances  produces  certain  changes  at  the  point 
of  entrance — the  initial  phenomena.  It  is  then  conveyed  by  the 
lymphatics  or  bloodvessels  to  near-by  organs  in  the  related  lymph-  or 
blood-stream,  or  transmitted  to  the  whole  body.  When  the  whole 
body  is  affected  an  eruption  is  sometimes  produced  (eruptive  fever), 
or  the  blood  is  changed  in  quality  (diphtheria),  or  many  tissues  are 
affected  simultaneously,  or  the  nervous  system  notably  disturbed.  The 
above  are  the  phenomena  of  general  distribution  of  the  virus,  or  of  infec- 
tiveness.  The  virus  or  poison  thus  distributed  may  be  the  living  organ- 
ism, as  in  tuberculosis  or  anthrax,  or  it  may  be  a  poison  generated  by 
the  organism,  a  toxin  or  ptomaine,  as  in  diphtheria. 

Phenomena  of  secondary  local  distribution  are  due  to  local  changes 
in  organs  affected  secondarily.  The  poison  has  a  special  affinity  for 
certain  organs,  as  in  whooping-cough,  parotitis,  pneumonia,  or  leprosy. 

In  some  instances  the  local  phenomena  are  so  marked  as  to  give  to 
the  disease  a  corresponding  distinctive  feature.  They  are  the  granulo- 
mata.  Bearing  in  mind  the  above  distinctions,  specific  infectious  dis- 
eases are  divided  into  six  classes. 

First  Class.  Acute  Specific  Fevers.  The  initial  phenomena  are 
slight.  The  phenomena  of  infectiveness  are  marked;  an  eruption  is 
one  of  the  most  characteristic.  The  secondary  local  phenomena  are 
variable.  The  following  are  included  in  this  class:  Typhoid  fever, 
typhus  fever,  variola,  varicella,  scarlet  fever,  measles,  relapsing  fever, 
rubella,  influenza,  denuge,  the  plague,  and  cholera. 

Second  Class.  Specific  Inflammation.  Initial  phenomena  indefi- 
nite. General  phenomena  (infectiveness)  variable,  but  no  eruption. 
Specific  affinity  of  poison  for  one  particular  structure.  Whooping- 
cough,  mumps,  diphtheria,  dysentery,  erysipelas,  tetanus,  hydrophobia, 
pneumonia  belong  to  this  class. 

Third  Class.  Contagious  Suppurations.  Initial  phenomena  marked 
(suppuration) ;  generalization  not  marked  unless  the  virus  enters  the 
blood  ;  secondary  local  phenomena  decisive.  Gonorrhoea  is  one  type, 
pyaemia  a  second,  in  which  the  blood  is  infected. 

Fourth  Class.  Infective  Granulomata.  Distinct  initial  phenom- 
ena.    Phenomena  of  generalization  not  marked,  or  like  specific  fevers. 

49 


770  SPECIAL  DIAGNOSIS. 

Secondary  local  phenomena  prominent.  Examples:  Tuberculosis, 
syphilis,  leprosy,  and  glanders. 

Fifth  Class.     Miasmatic  Diseases.     ~No  initial  phenomena. 

Sixth  Class.     Vegetable  Parasitic  Diseases. 

The  infectious  diseases,  not  discussed  in  this  section,  as  pneumonia 
and  dysentery,  are  considered  under  local  diseases  as  a  matter  of  con- 
venience. 

Remarks  on  the  Diagnosis  of  Infectious  Diseases. 

A  satisfactory  diagnosis  is  made  only  when  a  correct  appreciation  of 
the  evolution  of  the  disease  and  the  facts  concerning  its  activity  are 
ascertained.  The  eruptive  fevers,  particularly,  are  differentiated  with 
difficulty  unless  the  chronological  sequence  of  the  phenomena  of  the 
development  of  the  disease  are  weighed.  These  facts  in  a  suspected 
case  relate  to  the  history  of  exposure  of  the  patient,  the  presence  of 
an  epidemic,  the  presence  of  conditions  favorable  to  the  development  of 
the  disease,  etc.     The  following  should  be  ascertained: 

1.  The  occurrence  of  an  epidemic.  In  a  suspected  case  it  may  be 
of  weight  in  aiding  in  the  distinction  of  the  disease. 

2.  The  history  of  exposure  to  the  suspected  infection,  either  mediate 
or  immediate,  remotely  in  time  or  place,  must  have  great  value. 

3.  Immunity,  acquired  or  artificial,  to  a  particular  disease,  may 
exclude  that  affection.  The  eruptive  fevers  rarely  occur  a  second 
time. 

One  attack  of  erysipelas,  however,  predisposes  to  subsequent  attacks. 

4.  ^Etiological  facts  pertaining  to  the  suspected  disease,  as  unhygienic 
surroundings,  a  malarial  region,  etc.  Other  factors  bearing  on  aetiol- 
ogy, as  the  season  in  cases  of  typhoid  fever,  are  often  valuable  in 
pointing  to  the  affection. 

5.  The  Age.  The  eruptive  fevers  are  peculiar  to  childhood,  typhoid 
fever  to  early  adult  life. 

6.  The  occupation  in  affections  transmitted  from  animals  to  man. 

7.  The  duration  of  incubation,  the  mode  of  onset,  the  mode  of 
development,  the  characters  of  specific  features,  and  the  day  of  the 
development  of  each,  are  important  data  to  aid  the  diagnosis. 

Typhoid  Fever. 

An  acute,  specific,  infectious,  and  mildly  contagious  fever,  character- 
ized by  a  gradual  onset,  a  continued  fever,  an  eruption  of  rose-colored 
spots,  marked  nervous  and  abdominal  symptoms,  and  an  average  dura- 
tion of  three  or  four  weeks. 

It  occurs  sporadically  and  epidemically,  and  in  large  cities  is  apt  to 
be  epidemic.  Its  special  habitat  is  in  temperate  climates,  but  it  may 
occur  anywhere.  It  is  relatively  rare  in  the  southern  and  southwestern 
portions  of  the  United  States.  It  is  more  frequent  in  the  latter  part 
of  the  summer  and  in  the  autumn  and  winter,  and  following  hot  and 
dry  summers.  Young  adults  are  especially  prone  to  it,  but  cases  have 
occurred  at  all  ages.     Change  of  residence  from  the  country  to  the  city 


THE  INFECTIOUS  DISEASES.  771 

predisposes  to  it.  Those  living  in  cities  often  acquire  immunity,  but 
they  may  lose  it  upon  moving  elsewhere.  The  state  of  previous  health 
does  not  seem  to  have  any  influence. 

In  by  far  the  larger  number  of  epidemics  the  poison  has  been  con- 
veyed in  the  water,  in  a  few  instances  in  milk  previously  contami- 
nated by  water.  In  sporadic  and  endemic  cases  the  poison  may  be 
obtained  from  defective  house- drainage  and  from  damp,  unwholesome 
cellars.  The  specific  cause  of  the  disease  is  believed  to  be  a  bacillus 
described  by  Eberth  and  others. 

The  period  of  incubation  in  typhoid  fever  varies  from  four  or  five 
days  to  three  weeks;  more  commonly  it  is  from  one  to  two  weeks. 
During  this  time  the  patient  usually  is  languid,  becomes  tired  easily 
upon  exertion,  has  severe  headache,  and  sleeps  poorly.  There  is  often, 
even  thus  early,  a  dull  and  listless  expression  of  the  face.  Toward 
the  close  of  this  period,  and  in  severe  cases,  there  may  be  colicky  pain 
in  the  abdomen,  a  tendency  to  looseness  of  the  bowels,  cough,  epistaxis, 
mental  sluggishness,  and  chilliness.  Dr.  Pepper  says  he  has  been  led 
repeatedly  to  anticipate  the  approach  of  typhoid  fever  by  the  unusual 
dulness  of  hearing  and  by  the  persistent  occipital  headache  coming  on 
after  a  few  days  of  general  malaise. 

While  the  disease  may  begin  abruptly,  a  gradual  onset  is  so  much 
the  rule  that  it  becomes  important  in  the  diagnosis  from  other  disease- 
conditions. 

Invasion  is  not  sharply  marked.  There  may  be  chilliness,  but  a 
decided  chill  is  unusual  except  when  pneumonia  is  part  of  the  initial 
process.  Muscular  weakness,  headache,  and  mental  sluggishness  are 
more  pronounced,  and  the  physician  is  consulted  because  these  symp- 
toms persist,  or  because  fever  is  discovered.  The  beginning  of  fever 
is  the  most  constant  indication  of  the  onset  of  the  disease,  and  two 
very  important  early  symptoms  are  cough  from  bronchitis,  and  enlarge- 
ment of  the  spleen. 

The  most  prominent  and  constant  subjective  symptom  during  the 
first  week  is  headache.  Other  very  common  symptoms  are  tenderness, 
rarely  pain,  in  the  iliac  region,  more  or  less  prostration,  and  impaired 
appetite  or  loss  of  appetite. 

The  objective  symptoms  are  therefore  the  most  important.  The  face 
is  pale  rather  than  flushed,  and  has  a  dull,  listless,  apathetic  expression. 
The  tongue  is  heavily  coated  with  a  white  fur  which  later  becomes 
yellow.  The  abdomen  is  somewhat  distended  and  tympanitic  on  per- 
cussion. There  is  usually  tenderness  in  the  right  iliac  region,  and 
gurgling  upon  palpation  is  pretty  constant.  Constipation  may  be  present 
at  first,  and  sometimes  persists  throughout  the  disease.  A  tendency  to 
diarrhoea  is,  however,  characteristic  of  the  disease.  Even  if  constipa- 
tion exist  at  first,  a  laxative  is  apt  to  produce  an  excessive  effect.  The 
number  of  stools  varies  from  two  or  three  to  a  dozen  or  more  in  twenty- 
four  hours.  They  are  light  yellow  in  color  (resembling  pea-soup),  thin, 
watery,  and  offensive.  The  movements  are  not  usually  attended  with 
pain,  and  in  severe  cases  may  occur  involuntarily. 

Enlargement  of  the  spleen  is  a  very  constant  symptom.  It  may  be 
detected  at  the  onset,  increases  up  to  the  height  of  the  fever,  subsided 


772 


SPECIAL  DIAGNOSIS. 


during  convalescence,  but  recurs  during  a  relapse.     It  covers  a  percus- 
sion-area in  the  left  hypochondriuin  of  four  to  eight  finger-breadths. 

The  temperature-curve  when  not  modified  by  treatment  shows  a  grad- 
ual^ascent  during  the  first  four  or  five  days  of  the  disease,  with  morn- 
ing remission.  The  temperature  rises  a  degree  or  two  in  the  evening 
and  falls  half  a  degree  or  a  degree  in  the  morning.  This  "  step-ladder  " 
ascent  is  very  characteristic.  By  the  end  of  a  week  a  temperature  of 
103°,  104°,  or  105°  has  been  reached,  and  it  remains  continuously 
high,  with  slight  morning  remissions,  during  the  second,  and  less  fre- 
quently during  the  third  week.  In  the  third  or  fourth  week  the  morn- 
ing fall  of  temperature  gradually  becomes  greater,  and  by  the  end  of 
the  week  sinks  below  the  normal  in  the  morning. 

Fig.  147. 


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The  temperature  in  mild  cases  may  never  rise  above  103°  at  any 
time,  and  most  of  the  time  varies  between  100°  and  102°.  Or  it  may 
be  104°  from  the  start;  more  frequently  during  the  second  and  third 
weeks  there  are  marked  oscillations  of  the  temperature — a  sudden  fall 
from  104°  to  101°,  or  a  rise  from  103°  to  105°  or  106°.  Hyperpyrexia 
is  a  temperature  above  105°. 

The  pulse  is  full,  and  in  favorable  cases  slower  than  the  pyrexia  would 
lead  one  to  expect.  It  is  more  frequently  under  110  than  over  120. 
In  the  second  week  it  is  markedly  dicrotic. 

The  heart-sounds  are  unchanged  apart  from  complications,  but  in  the 
second  and  third  weeks  the  first  sounds  often  are  feeble,  indicating 
heart- weakness.  A  pulse  of  120  or  more  is  a  graver  sign  in  typhoid 
fever  than  in  other  diseases.  Therefore  when  it  becomes  very  frequent 
and  feeble,  the  extremities  cool  and  the  lips  bluish,  the  outlook  is 
gloomy. 

The  urine  is  at  first  scanty  and  high-colored.  A  slight  degree  of 
febrile  albuminuria  is  not  uncommon,  and  in  rare  cases  the  whole  force 
of  the  poison  seems  to  be  spent  upon  the  kidneys,  the  urine  containing, 
besides  the  usual  blood  and  casts,  biliary  coloring-matter.  In  condi- 
tions bordering  on  coma  the  patient  may  have  retention  of  urine,  or, 


THE  INFECTIOUS  DISEASES. 


773 


774  SPECIAL  DIAGNOSIS. 

on  the  other  hand,  he  may  pass  it  involuntarily.  To  obtain  the  diazo- 
reaction  of  Ehrlich  two  solutions  are  necessary.  The  first  (a)  consists 
of  2  grams  of  sulphanilic  acid,  50  c.c.  hydrochloric  acid,  and  distilled 
water  1000  c.c.  The  second  (b)  consists  of  a  J  per  cent,  solution  of 
sodium  nitrite.  These  solutions  are  kept  in  separate  bottles.  Fifty 
parts  of  solution  a  and  one  part  of  solution  b  are  poured  into  a 
test-tube  and  an  equal  volume  of  urine  added.  The  test-solutions 
and  urine  are  now  thoroughly  shaken  and  then  carefully  overlaid  with 
1  c.c.  of  ammonia.  At  the  junction  of  the  two  a  pink  or  ruby  ring 
develops.  Upon  agitation  the  foam  on  the  top  of  the  mixture  is  also 
colored  red.  Normal  urines  give  a  light-brown  ring.  This  reaction 
is  helpful  in  diagnosis,  but  may  occur  in  acute  phthisis,  tubercular 
meningitis,  and  other  diseases.  According  to  Pepper,  it  is  rarely 
absent  in  measles.  The  reaction  is  fairly  constant  in  typhoid  fever 
after  the  first  week. 

The  respiration  in  uncomplicated  cases  increases  in  frequency  with 
the  rise  in  temperature.  It  usually  ranges  between  24  and  36.  The 
slight  bronchitis  present  in  the  beginning  in  most  cases  causes  no 
trouble;  sometimes  it  lasts  throughout  and  contributes  to  the  tendency 
to  hypostatic  congestion,  which  is  always  present.  The  physical  signs 
are  those  described  elsewhere  in  these  conditions. 

The  nervous  symptoms  are  often  very  prominent.  In  mild  cases  they 
consist  of  hebetude  and  nocturnal  delirium,  or  they  may  be  absent 
altogether.  Usually,  however,  by  the  beginning  of  the  second  week 
there  is  some  mental  confusion,  with  nocturnal  delirium.  In  more 
severe  cases  and  later  in  the  disease  the  delirium  is  of  a  low,  mutter- 
ing character,  with  hallucinations  of  sight  and  sound  more  or  less  con- 
tinuous. The  patient  can  be  roused  by  a  question,  and  makes  an 
intelligent  answer,  but  speedily  lapses  into  semi-consciousness.  Pick- 
ing at  the  bedclothes  or  efforts  to  catch  imaginary  objects  are  very 
common.  Sometimes  the  delirium  is  wild  and  noisy,  and  the  constant 
presence  of  some  one  is  needed  to  keep  the  patient  from  getting  out  of 
bed.  Patients  have  jumped  out  of  windows,  or  run  long  distances 
before  being  captured.  Rarely  the  delirium  has  been  so  active  as  to 
simulate  acute  mania.  Stupor  may  alternate  with  delirium.  Rarely 
the  patient  lies  with  wide-open  eyes,  apparently  staring  fixedly  at 
some  object,  but  really  unconscious  (coma-vigil). 

In  ataxic  cases  the  patient  has  marked  twitching  of  the  tendons  and 
jactitation.  He  is  wakeful  and  restless,  wearing  himself  out.  The 
hands  and  lips  tremble,  and  he  keeps  muttering  to  himself  all  the  time. 

Convulsions  are  rare,  but  may  occur  in  children.  Sometimes  there 
are  considerable  hyperesthesia  and  tenderness  along  the  spine. 

The  extent  of  the  nervous  symptoms  depends  upon  the  habit  of  the 
patient  as  well  as  upon  the  height  of  the  temperature  and  gravity  of 
the  disease.  In  children  and  neurotic  individuals  they  may  be  pro- 
nounced, with  only  moderate  fever. 

On  the  seventh  or  eighth  day  the  eruption  appears.  It  consists  of 
small,  very  slightly  elevated,  rose-colored  papules,  which  disappear 
upon  pressure  and  come  out  in  successive  crops,  each  papule  lasting 
three  or  four  days.     The  spots  are  most  common  over  the  abdomen 


THE  INFECTIOUS  DISEASES. 


775 


and  back,  but  are  occasionally  found  elsewhere.  They  are  usually  few 
in  number,  a  half-dozen  or  dozen,  but  sometimes  the  eruption  is  very 
copious,  especially  in  severe  cases.     Sometimes  it  is  wholly  absent. 


Fig.  149. 


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Grave  typhoid  fever.    Death.    M.,  set.  22  years.    Ataxic  symptoms. 
Fig.  150. 


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Typhoid  fever  in  a  child  aet.  12  years.    Chart  from  twelfth  to  twenty-third  day. 
(Frequent  mode  of  termination  in  children.) 

During  the  latter  part  of  the  second  week  and  through  the  third 
week  the  symptoms  are  apt  to  be  intensified.  The  temperature  keeps 
up  or  even  reaches  a  higher  point.     Delirium  is  more  decided  and  con- 


776 


SPECIAL  DIAGNOSIS. 


stant.  The  heart  grows  weak  and  the  pulse  increases  in  frequency. 
Some  degree  of  hypostatic  congestion  of  the  lungs  is  usual.  Diarrhoea 
may  be  troublesome;  intestinal  hemorrhages,  announced  by  sudden  fall 
of  temperature  and  symptoms  of  collapse,  may  occur.  Tympanites 
may  become  so  great  as  to  interfere  with  respiration  and  circulation. 
This  is  the  period  when  ulceration  of  Peyer's  patches  in  the  intestine  is 
deepest,  and  when  perforation  is  imminent.  There  is  rarely  any  desire 
for  food,  though  it  is  taken  and  assimilated.  Nausea  and  vomiting 
are  rare.  The  tongue  is  dry,  brown,  sometimes  glazed  and  fissured, 
and  sordes  often  collect  on  the  teeth. 


Fig.  151. 


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Course  of  temperature  in  a  relapse  beginning  on  the  twenty-sixth  day.    First  attack  mild. 

In  cases  ending  in  recovery  the  temperature  begins  to  fall  in  the 
mornings;  delirium  grows  less;  sleep  is  more  refreshing.  Diarrhoea 
ceases,  and  constipation  may  even  require  treatment.  The  pulse  does 
not  usually  improve  as  rapidly  as  the  other  symptoms.  There  is  some- 
times very  marked  anaemia  without  leucocytosis  (Osier).  When  the 
temperature  sinks  to  normal  or  subnormal,  convalescence  has  set  in. 
This  is  very  rapid  as  far  as  digestive  symptoms  are  concerned,  but 
strength  returns  very  slowly.  It  may  be  interrupted  by  a  relapse,  in 
which  the  original  symptoms  are  reproduced,  with  high  temperature, 
but  the  duration  is  shorter. 

Varieties.  The  abortive  form  is  so  named  because  of  the  abbre- 
viated course  of  the  disease.  The  symptonls  are  sufficiently  well  marked 
to  make  the  diagnosis  clear,  but  the  type  is  mild,  and  in  a  week  or  two 
convalescence  is  established. 

In  the  ambulatory  form,  commonly  called  "  walking  typhoid,"  the 
patient,  from  ignorance  of  the  gravity  of  his  ailment  or  from  apparent 
necessity,  keeps  at  his  work  until  weakness  and  incessant  headache  lead 


THE  INFECTIOUS  DISEASES. 


Ill 


him  to  consult  a  physician  in  his  office  or  at  a  dispensary.  He  may 
then  be  well  into  the  second  week  of  the  disease.  The  majority  of 
such  cases  prove  fatal. 

In  the  pulmonary  form  the  onset  may  be  so  obscured  by  severe  bron- 
chitis or  lobar  pneumonia  that  the  primary  disease  is  not  suspected  at 
first.  Severe  bronchitis  seems  to  be  more  common  in  children.  Chill 
and  initial  high  temperature  are  common  in  these  cases. 


Fig.  152. 


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Grave  typhoid  fever.    Daily  rigors.    Death  on  nineteenth  day.    No  complications. 


Grave  forms  are  due  to  especial  severity  of  some  symptoms  or  group 
of  symptoms,  such  as  hyperpyrexia;  profound  stupor,  coma,  or  intense 
ataxia;  inability  to  take  or  retain  sufficient  nourishment;  profuse  diar- 
rhoea and  intestinal  hemorrhage;  great  adynamia  with  weak  heart  and 
a  tendency  to  cyanosis.  In  other  cases  the  gravity  results  from  the 
existence  of  complications. 

In  the  malignant  form  there  lias  been  a  large  dose  of  the  poison  or 
a  very  weak  organism,  or  both,  the  result  being  an  acute  toxaemia;  this 
is  not  so  common  as  in  scarlatina. and  typhus  fever.  Other  relatively 
rare  forms  are  the  renal  and  afebrile. 

Complications  and  Sequelae.  Typhoid  fever  may  be  accom- 
panied by  a  number  of  complications,  the  most  frequent  and  important 


778 


SPECIAL  DIAGNOSIS. 


being  severe  bronchitis,  hypostatic  congestion  with  oedema,  and  true 
lobar  pneumonia;  bedsores:  parotitis;  phlebitis,  especially  of  the 
femoral  vein;  peritonitis  from  perforation  of  the  bowel;  meningitis, 
acute  mania,  or  mental  decay;  jaundice;  myocarditis;  periostitis  and 
osteitis.  Sequelae  are  not  frequent.  Sometimes,  however,  the  founda- 
tion is  laid  for  permanent  ill  health.  There  may  be  impairment  of  the 
senses,  mental  weakness,  and  even  insanity.  Paralyses,  neuritis,  hyper- 
esthesias, chorea,  and  epilepsy  are  occasional  sequels. 


Fig.  153. 


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Renal  typhoid.    Nephritis  on  the  twenty-fifth  day.    Course  of  temperature  during 
three  days  preceding  death. 

Bacteriological  Diagnosis.  Eberth's  Bacillus.  The  bacillus  is 
found  in  colonies  in  the  spleen,  liver,  mesenteric  glands,  kidneys,  and 
intestines.  It  is  also  found  in  the  feces  and  rarely  in  the  urine.  It 
may  be  seen  in  the  blood. 

MorpKology.  A  bacillus  1  to  3^  long  by  0.5  to  0.8/*  broad,  with 
rounded  ends.  It  is  motile,  facultative  anaerobic,  does  not  liquefy 
gelatin.  It  has  flagella  3.  to  5  times  as  long  as  the  bacilli.  It  stains 
with  the  anilines,  best  with  Loffler's  blue.  The  flagella  are  stained  by 
Loffler's  special  method  (see  Plate  II.,  Fig.  6,  b). 

Biological  Properties.  It  grows  readily  in  acid  media  as  well  as  in 
the  neutral  or  alkaline  media,  best  at  a  temperature  of  38°  C.  (Death- 
point,  60°  C.) 

The  organ  from  which  a  culture  is  to  be  made  is  washed  carefully  in 
a  bichloride  of  mercury  solution.  Then  three  cuts  are  made  with  dif- 
ferent sterilized  knives,  the  third  cut  reaching  the  central  part  of  the 


THE  INFECTIO  US  DISEASES.  779 

organ.  A  little  of  the  tissue  is  then  taken  with  a  platinum  needle  and 
inserted  into  the  tubes. 

The  colonies  develop  in  twenty-four  to  forty-eight  hours.  On  gel- 
atin plates  they  are  small  and  white,  nearly  spherical;  irregular,  gran- 
ular, and  yellowish-brown. 

In  stab-cultures  there  is  a  whitish  semi-transparent  layer  on  the  sur- 
face, with  sharply  defined  irregular  edges,  and  along  the  puncture  a 
grayish- white  growth  (see  Plate  I.,  Fig.  5). 

It  develops  abundantly  in  milk.  On  potato  it  forms  an  "  invisible 
growth,"  manifested  only  by  increase  in  moisture,  which  is  quite  char- 
acteristic. 

Bacteriological  Diagnosis.  It  would  be  most  desirable  if  a  means 
of  diagnosis,  that  would  have  no  element  of  uncertainty  about  it, 
could  be  found.  Bacteriologists  have  sought  for  such  means,  and  at 
present  seem  to  have  found  two  methods,  one  of  which  at  least  has 
been  brought  to  such  a  degree  of  perfection  as  to  be  of  value  to  the 
clinician.  They  are  Eisner's  culture  and  Pfeiffer's  bactericidal  serum 
methods.  Eisner's  method1  consists  in  the  preparation  of  a  culture- 
medium  upon  which  no  species  of  micro-organism  can  grow  except  the 
typhoid  bacillus  and  the  bacillus  coli  communis.  Such  a  medium  is 
prepared  as  follows :  To  half  a  kilogram  of  chopped  potatoes  add  one 
litre  of  water,  and  boil  for  one  and  one-half  hours.  Strain  through 
cloth,  and  add  10  per  cent,  of  glycerine.  The  degree  of  acidity  of 
the  mixture  must  be  such  that  each  10  c.c.  should  require  2.5  c.c.  of 
a  decinormal  soda  solution  to  neutralize  it.  One  per  cent,  of  potassium 
iodide  is  finally  added,  and  the  medium  is  completed.  The  potassium 
iodide  should  not  be  added  until  shortly  before  use.  Upon  this  mix- 
ture nearly  all  micro-organisms  except  the  bacillius  coli  communis  and 
the  typhoid  bacillus  either  do  not  grow  at  all  or  are  greatly  inhibited. 
At  the  end  of  twenty-four  hours  the  colonies  of  the  colon-bacilli  can 
easily  be  found  by  the  aid  of  a  low-power  objective,  while  those  of  the 
typhoid  bacilli  are  scarcely  visible.  At  the  end  of  forty-eight  hours 
the  colonies  of  the  typhoid  bacillus  appear  as  small,  very  finely  granu- 
lar points,  while  those  of  the  colon- bacillus  are  larger,  coarser,  and 
much  more  highly  colored.  A  possible  source  of  error  has  been  de- 
tected by  Pollak,2  who  states  that  the  bacillius  faecalis  alcaligenes,  a 
micro-organism  very  similar  to  the  typhoid  bacillus,  is  found  in  the  stools 
of  persons  not  suffering  from  typhoid  fever.  The  points  of  distinc- 
tion between  the  two  are  that  the  bacillus  fsecalis  alcaligenes  renders 
litmus-whey  turbid  in  twenty-four  hours  and  alkaline  in  forty-eight 
hours,  while  the  bacillus  of  typhoid  produces  an  acid  reaction  and  the 
medium  remains  clear.  The  colon-bacillus  renders  the  whey  turbid, 
but  the  acid  reaction  is  much  more  intense. 

Pfeiffer's  method,  while  of  interest  and  full  of  suggestions  as  to  its 
future  usefulness,  cannot  be  applied  with  sufficient  ease  to  render  it 
practical  for  clinical  work. 

Diagnosis.  A  typical  case  of  typhoid  fever  ought  not  to  be  mis- 
taken for  any  other  affection,  but  atypical  cases  are  numerous.     The 

1  Zeit.  Hvgien.  und  Infection  kr.,  B.  21,  H.  1. 

2  Ceutralblatt  f.  inn.  Med.,  18%,  31. 


780  SPECIAL  DIAGNOSIS. 

most  common  sources  of  error  are  a  hurried  diagnosis  and  a  willingness 
to  accept  a  demonstrable  local  affection  as  sufficient  to  account  for  the 
condition.  In  this  way  the  significance  of  bronchitis,  pneumonia,  and 
diarrhoea  is  overlooked.  In  the  symptomatic  form  there  will  almost 
always  be  found  a  history  of  gradual  onset  and  a  degree  of  fever  and 
prostration  greater  than  should  attend  the  purely  local  affection.  More- 
over, in  bronchitis  and  pneumonia,  which  are  a  part  of  typhoid  fever, 
there  may  be  found  tenderness  with  gurgling  in  the  right  iliac  region, 
enlargement  of  the  spleen,  and  epistaxis,  to  aid  in  the  diagnosis;  while 
in  cases  in  which  the  diarrhoea  leads  to  uncertainty,  bronchitis,  enlarge- 
ment of  the  spleen,  and  epistaxis  may  coexist. 

New  Diagnostic  Sign  of  Typhoid  Fever.  Dr.  Simon  Baruch  writes 
as  follows:  "As  soon  as  the  patient  shows  a  rectal  temperature  above 
102.5°  in  the  morning  and  103°  in  the  evening  for  three  successive 
days,  especially  if  this  be  accompanied  by  headache,  dulness,  or  apathy, 
he  is  placed  in  a  full  bath  at  90°,  which  is  reduced  to  80°,  with  con- 
stant friction  over  the  body.  In  three  hours,  the  temperature  still 
being  above  102.5°,  he  receives  another  bath  5°  cooler.  This  is 
repeated  until  the  temperature  of  the  bath  is  75°.  If  one  or  more  of 
these  baths  fail  to  reduce  the  rectal  temperature  2°  in  half  an  hour, 
the  diagnosis  of  typhoid  fever  is  almost  certain,  and  the  bath-treatment 
is  continued.  The  resistance  of  the  rectal  temperature  to  a  bath  of 
75°  for  fifteen  minutes,  with  friction,  is  an  almost  certain  test  of 
typhoid  fever.' n  Dr.  Baruch  considers  that  the  diagnosis  of  this  dis- 
ease should  no  longer  be  obscure,  even  in  the  first  days  of  its  course. 

Appendicitis  is  more  likely  to  be  mistaken  for  typhoid  fever  than 
the  converse.  There  is  usually  a  history  of  constipation,  though  the 
occurrence  of  several  inadequate  movements  a  day  may  conceal  the 
fact  that  there  is  a  fsecal  accumulation.  In  appendicitis  the  onset  is 
more  abrupt  and  the  local  symptoms  more  pronounced  than  in  typhoid. 
Pain  and  tenderness  are  prominent  in  appendicitis,  and  while  they  may 
be  general  over  the  abdomen  at  first,  they  are  found  to  be  more  acute 
in  the  iliac  region  and  loin.  Here,  in  place  of  gurgling,  we  find  some 
increase  of  resistance  on  palpation,  and  a  relatively  dull  note — a  wooden 
sort  of  tympany — or  there  may  be  a  demonstrable  tumor.  The  patient 
lies  with  the  right  leg  drawn  up,  has  moderate  fever,  and  vomiting. 
In  fact,  the  attack  is  often  introduced  by  chilliness  and  vomiting. 
Headache  is  not  a  prominent  symptom,  while  bronchitis  and  enlarge- 
ment of  the  spleen  are  absent. 

Acute  right-sided  salpingitis  simulates  typhoid  fever.  It  is  distin- 
guished by  the  history  of  a  preceding  vaginitis,  endometritis,  or  abor- 
tion, by  the  absence  of  diarrhoea,  of  enlargement  of  the  spleen,  and  of 
the  characteristic  eruption.  A  digital  examination  through  the  vagina 
discovers  the  womb  pressed  to  one  side  and  fixed,  and  a  tender  mass 
blocking  up  the  pelvis. 

Simple  continued  fever  is  distinguished  from  typhoid  fever  of  a  mild 
type  principally  by  the  absence  of  bronchitis,  of  enlargement  of  the 
spleen,  of  epistaxis,  and  of  the  characteristic  eruption  of  typhoid  fever. 

1  New  York  Medical  Journal,  September  2, 1893. 


THE  INFECTIO  US  DISEASES.  781 

In  simple  continued  fever  constipation  is  more  common  than  looseness 
of  the  bowels,  and  gurgling  is  absent. 

Typhus  fever  is  distinguished  by  its  sudden  onset,  the  besotted  expres- 
sion of  the  face,  with  reddened  eyelids  and  small  pupils,  the  absence 
of  abdominal  symptoms,  and  the  occurrence  on  the  fourth  day  of  mac- 
ulae, which  are  subsequently  converted  into  petechia?.  It  is  of  shorter 
duration,  and  terminates  very  abruptly  by  crisis. 

Relapsing  fever  differs  from  typhoid  fever  in  its  sudden  onset  with 
chill,  pain  in  the  epigastrium,  but  absence  of  abdominal  symptoms  and 
eruption;  in  the  absence  of  marked  nervous  symptoms,  in  spite  of  the 
high  fever;  the  short  duration  and  termination  by  crisis,  and  charac- 
teristic relapse  at  the  end  of  a  week.  The  conclusive  test  is  finding 
spirilla  in  the  blood. 

Acute  tuberculosis  of  the  lungs,  at  times,  closely  resembles  typhoid 
fever.  In  both  the  onset  is  gradual,  with  cough  and  fever.  In  the 
former,  however,  the  bronchial  symptoms  are  more  prominent,  there 
are  apt  to  be  recurring  chills  and  sweats,  the  temperature  is  remittent 
and  irregular,  emaciation  is  rapid,  and  constipation  instead  of  diarrhoea 
is  the  rule. 

In  peritoneal  tuberculosis  there  is  persistent  pain  in  the  abdomen, 
which  is  general;  the  belly  is  swollen.  If  effusion  occurs,  the  percus- 
sion-note is  dull.  The  temperature  is  irregular  and  may  be  below 
normal;  nervous  symptoms  comparable  to  those  of  typhoid  are  wanting. 

Meningitis  before  the  stage  of  effusion  exhibits  exaggeration  of  the 
reflexes  and  marked  hyperesthesia.  There  may  also  be  muscular 
rigidity.  The  patient  is  restless,  easily  annoyed,  and  "  fussy  "  about 
things  that  would  be  unnoticed  by  a  typhoid  patient.  Vomiting  is 
often  present,  whereas  it  is  rare  in  typhoid  fever.  The  temperature 
does  not  maintain  so  high  an  average  range  as  in  typhoid  and  is  sub- 
ject to  greater  oscillations.  The  pulse  varies  greatly,  and  may  be 
irregular. 

In  septic  meningitis  the  headache  and  vomiting  are  more  persistent, 
the  bowels  are  confined,  and  the  abdominal  walls  are  retracted.  There 
may  be  double  optic  neuritis.  In  tubercular  meningitis  the  knee-jerk 
and  other  reflexes  are  variable,  irregularly  absent  or  present.  In 
typhoid  fever  they  are  always  present.  In  the  former  choroidal  tuber- 
cles may  be  seen  with  the  ophthalmoscope.  In  tuberculosis  in  all  forms 
leucocytosis  is  present;  in  typhoid  it  is  absent.  Typhoid  fever  must 
not  be  confounded  with  trichiniasis ;  the  peculiar  muscular  pain  and 
cedema  do  not  occur  in  the  former.  TJrmmia  may  simulate  typhoid 
fever  when  it  becomes  chronic;  but  the  age,  the  character  of  the  urine, 
the  cardio-vascular  symptoms,  are  diagnostic,  and,  with  the  absence  of 
the  specific  typhoid  symptoms,  render  the  diagnosis  easy. 

Typhus  Fever. 

An  acute  contagious  fever,  occasionally  occurring  sporadically  and 
often  becoming  epidemic  in  the  presence  of  destitution,  filth,  over- 
crowding, and  bad  ventilation.  It  is  characterized  by  abrupt  onset 
with  chill  or  with  chilliness,  a  rapid  rise  of  temperature,  lassitude, 


782  SPECIAL  DIAGNOSIS. 

headache,  and  pains  in  the  back  and  limbs.  On  the  fourth  or  fifth  day 
a  peculiar  spotted  eruption  appears,  which  at  first  is  macular  and  sub- 
sequently petechial.  It  is  further  characterized  by  adynamia  or  ataxia, 
low  muttering  delirium,  a  suffused,  heavy,  drunken  expression  of 
countenance,  by  the  absence  of  local  disease,  and  by  a  crisis  which 
occurs  on  or  about  the  fourteenth  day. 

Typhus  fever  is  variously  known  as  ship-fever,  jail-fever,  camp- 
fever,  etc.,  names  which  sufficiently  indicate  its  tendency  to  develop 
in  the  presence  of  filth,  overcrowding,  and  privation.  It  is  rare  in 
this  country,  but  is  occasionally  introduced  at  our  seaports. 

The  period  of  incubation  is  usually  about  twelve  days;  it  may  be 
five  or  eight  days,  or  even  a  shorter  time, depending  upon  the  virulence 
of  the  poison  and  the  susceptibility  of  the  patient.  Malaise  may  pre- 
cede by  a  day  or  two  the  onset  of  the  disease. 

Invasion  is  characterized  by  headache,  faiutness,  vertigo,  chilliness, 
or  a  distinct  rigor,  pains  in  the  back  and  thighs,  loss  of  appetite,  nau- 
sea, constipation,  and  extreme  weakness.  The  prostration  is  sometimes 
so  great  as  to  compel  the  patient  at  once  to  go  to  bed.  The  temperature 
rises  rapidly  to  104°  or  105°  at  the  end  of  the  second  or  third  day. 
The  pulse  is  frequent,  100  or  140,  and  in  grave  cases  shows  a  marked 
tendency  to  become  small,  soft,  and  feeble.  The  patient  is  restless 
and  sleepless,  and  is  annoyed  by  tinnitus.  The  expression  of  the  flushed 
face  is  listless  and  dull. 

About  the  fourth  or  fifth  day  the  typhus  eruption  begins  to  appear. 
It  consists  at  first  of  dull  red  spots  of  irregular  size  and  shape.  They 
are  most  numerous  on  the  covered  parts.  Moore1  says  they  are  detected 
first  near  the  axilla?  and  on  the  wrists,  then  on  the  sides  of  the  abdo- 
men, afterward  on  the  chest,  back,  shoulders,  thighs,  and  arms.  The 
skin  is  also  mottled  by  another  crop  of  macula?  under  the  skin  ("  mul- 
berry rash  "). 

When  the  disease  is  fully  developed  the  face  is  flushed,  the  conjunc- 
tivae red,  the  pupils  contracted  so  as  to  resemble  pin-holes  ("ferrety 
eye"),  the  tongue  dry  and  brown,  the  teeth  covered  with  sordes,  the 
skin  dry,  hot,  and  stinging  to  the  touch.  The  patient  lies  upon  his  back 
oblivious  to  all  his  surroundings.  Headache  has  given  place  to  delirium, 
which  may  be  wild  and  fierce,  but  is  more  commonly  low  and  mutter- 
ing. There  are  marked  ataxic  symptoms — subsultus  tendinum,  tre- 
mors, picking  at  the  bedclothes.  Incontinence  of  urine  and  fasces 
sometimes  occurs.  The  breathing  is  frequent,  shallow,  and  noisy,  and 
the  pulse  frequent,  soft,  and  feeble.  The  macular  rash  now  becomes 
petechial.  The  patient  is  in  a  typical  "  typhoid  state."  The  stupor 
may  gradually  clear  up,  or,  on  the  other  hand,  deepen  into  coma;  or 
the  patient  may  die  from  progressive  weakening  of  the  heart,  with  or 
without  pulmonary  complications. 

In  the  majority  of  favorable  cases,  on  or  about  the  fourteenth  day, 
the  first  sign  of  recovery  is  a  sound  sleep,  from  which  the  patient 
awakes  refreshed  and  rational.  The  temperature  falls  with  great 
rapidity,  the  pulse  and  temperature  improve;  a  typical  crisis  has 
occurred. 

1  Eruptive  and  Continued  Fevers,  by  J.  W.  Moore,  Dublin,  1892. 


THE  INFECTIOUS  DISEASES.  783 

Certain  objective  phenomena  of  the  disease  require  special  mention. 
The  eruption  is  more  copious  in  severe  than  in  mild  cases.  A  dull  and 
livid  color  is  a  grave  sign.  Purpura  and  hemorrhages  are  sometimes 
met  with  in  bad  cases.    The  eruption  does  not  occur  in  successive  crops. 

The  patient  seems  to  be  surrounded  by  a  vapor  of  a  pungent,  musty 
odor  which  is  peculiar. 

The  heart  early  shows  the  effect  of  the  poison.  The  impulse  is 
diminished,  and  the  first  sound  is  less  distinct.  In  grave  cases  with 
threatening  heart-failure  the  sounds  are  feeble  and  distant,  the  impulse 
imperceptible. 

The  pulse  is  usually  very  much  more  frequent  than  normal,  but 
may  be  abnormally  slow  (50  and  even  30  per  minute);  this  is  some- 
times a  bad  sign. 

The  weak  heart  and  prostrate  position  of  the  patient  favor  congestion 
with  oedema  of  the  lungs.     This  condition  is  common. 

Digestive  symptoms  have  been  referred  to  already.  Vomiting,  tym- 
panites, and  diarrhoea  are  rare,  and  still  more  so  is  intestinal  hemor- 
rhage. 

The  urine  is  scanty  and  high-colored.  Slight  albuminuria  is  common, 
and  a  few  casts  are  found,  but  distinct  nephritis  is  unusual.  Convul- 
sions, when  they  occur  after  the  first  week,  are  almost  always  urseinic 
and  almost  invariably  fatal.  They  may  be  due  to  retention  of  the 
urine,  as  recorded  by  Stokes  and  Corrigan. 

The  duration  of  the  disease  is  from  six  to  fifteen  days;  the  average 
period  is  twelve  to  fourteen  days.  An  abortive  form  is  met  with  in 
some  epidemics,  the  disease  being  of  a  mild  type  and  subsiding  at  the 
end  of  a  week.  In  some  cases  so  large  a  dose  of  the  poison  is  absorbed 
by  the  patient  that  he  is  stricken  down  in  a  few  hours  or  a  few  days. 
To  this  form  the  name  ' '  blasting  typhus ' '  has  been  appropriately 
given.  The  most  important  complications  are  hyperpyrexia,  laryngitis, 
bronchitis,  and  congestion  of  the  lungs,  extreme  ataxia  or  profound 
adynamia,  nephritis,  heart-failure,  and  parotitis,  or  other  inflammatory 
glandular  swellings. 

Laryngitis  with  oedema  is  a  very  rare  but  very  dangerous  complica- 
tion. 

Diagnosis.  Cerebrospinal  fever  is  distinguished  from  typhus  fever 
by  greater  intensity  of  the  headache,  by  retraction  of  the  head  and 
hypersesthesia,  by  greater  liability  to  vomiting,  and  by  the  absence  of 
the  macular  petechial  eruption,  and  the  drunken,  besotted  aspect  of 
typhus  fever.  In  cerebro-spinal  fever  the  patient  suffers  with  photo- 
phobia and  is  liable  to  local  palsies  of  the  eye-muscles  (strabismus)  and 
to  general  convulsions.  Convulsions  do  not  occur  in  typhus  except 
from  a  complicating  nephritis  or  retention  of  urine. 

TJrazrnia  is  distinguished  from  typhus  by  the  preceding  history,  by 
the  absence  of  high  temperature,  and  by  the  presence  of  cedema  of 
the  face  or  extremities,  a  history  of  vomiting  or  diarrhoea  preceding 
the  stupor.  The  condition  of  the  urine  and  the  absence  of  eruption 
are  the  final  tests. 

Pneumonia  is  distinguished  by  the  frequent  respiration  and  relatively 
slower  pulse,  and  by  the  local  physical  signs  and  absence  of  eruption. 


784  THE  INFECTIO  US  DISEASES. 

Typhoid  fever  is  distinguished  by  its  slow  onset  and  marked  abdom- 
inal symptoms.  The  eruption  of  typhus  is  petechial  and  comes  out  on 
the  fourth  or  fifth  day;  that  of  typhoid  fever  consists  of  rose-spots,  and 
appears  on  the  seventh  or  eighth  day.  In  typhus  fever  the  severe 
initial  chill,  the  sudden  onset,  the  greater  prostration,  and  the  earlier 
appearance  of  cerebral  symptoms  are  helpful  in  distinguishing  it  from 
typhoid  fever. 

Relapsing-  Fever. 

An  acute  infectious  and  contagious  fever,  occurring  in  epidemics  and 
characterized  by  the  sudden  onset  of  a  febrile  period  lasting  five  or 
seven  days,  which  is  followed  by  an  intermission  lasting  usually  a  week, 
and  this  in  turn  by  a  relapse  lasting  three  days.  Its  development  is 
favored  by  filth  and  famine,  but  the  specific  cause  is  believed  to  be  the 
spirillum  of  Obermeier,  which  is  constantly  present  in  the  blood  during 
the  febrile  stage. 

The  stage  of  incubation  lasts  from  five  to  eight  days  (Pepper),  during 
which  the  patient  may  complain  of  malaise,  lassitude,  and  flying  pains. 
The  invasion  is  sudden.  It  manifests  itself  by  a  chill  or  chills,  frontal 
headache,  pains  in  the  back  and  limbs,  vertigo,  and  great  physical 
weakness.  The  temperature  rises  very  rapidly,  reaching  105°,  106°, 
or  even  higher,  in  the  first  day  or  two.  The  iace  is  flushed,  epistaxis 
sometimes  occurs,  the  headache  and  other  pains  persist,  but  delirium 
is  not  common.  The  appetite  is  usually  lost,  thirst  intense,  the  tongue 
coated  white  but  moist,  the  bowels  constipated.  A  mild  catarrhal  jaun- 
dice is  not  infrequent.  Pepper  states  that  nausea  and  vomiting  are 
prominent  symptoms,  the  matters  vomited  at  times  containing  blood. 
Tenderness  with  pain  in  the  epigastrium  is  frequently  complained  of. 

The  urine- is  scanty,  high-colored,  and  frequently  contains  albumin 
and  casts;  when  jaundice  exists,  the  urine  contains  bile-pigment  and 
sometimes  blood. 

There  is  no  peculiar  eruption  in  relapsing  fever,  but  in  this,  as  in 
other  fevers,  erythemata,  petechias,  and  sudamina  may  be  present. 

The  pulse  is  often  very  frequent  and  soft,  and  hsemic  murmurs  may 
be  audible. 

The  objective  symptoms  are  few.  They  consist  of  the  flushed  face, 
sometimes  with  slight  jaundice  and  epistaxis,  tenderness  in  the  epigas- 
trium, with  moderate  enlargement  of  the  spleen  and  liver,  and  consider- 
able cutaneous  hyperesthesia,  with  tenderness  along  the  nerve-trunks. 

Bronchitis  and  sometimes  hypostatic  congestion  of  the  lungs,  with 
their  usual  physical  signs,  may  be  present. 

These  symptoms  continue  without  much  change  until  the  fifth  or 
seventh  day,  when  a  decided  crisis  occurs.  Sometimes  this  is  deferred 
until  the  tenth  day.  The  temperature  within  twelve  hours  falls  from 
106°  or  108°  to  or  below  normal;  the  pulse  diminishes  in  frequency 
from  120  or  130  to  60  or  70;  vertigo,  headache,  and  other  pains  disap- 
pear as  by  magic.  The  crisis  is  marked  most  frequently  by  a  profuse 
sweat,  sometimes  by  diarrhoea,  epistaxis,  metrorrhagia,  or  intestinal 
hemorrhage.  The  patient  now  enters  upon  convalescence  without 
fever,  and  apparently  makes  rapid  strides  toward  complete  recovery- 


THE  INFECTIOUS  DISEASES.  785 

On  the  seventh  day  from  the  crisis,  however,  a  sudden  relapse  occurs, 
with  a  repetition  of  the  symptoms  of  the  first  attack.  The  temperature 
may  be  higher  and  the  febrile  symptoms  more  severe,  but  the  duration 
is  shorter — only  three  or  four  days.  The  spirilla,  which  disappeared  in 
the  apyretic  interval,  are  again  found  in  abundance.  A  second  crisis, 
with  its  associated  symptoms,  now  occurs.  The  spirilla  again  disap- 
pear, and  in  the  majority  of  the  cases  there  is  eo  further  bar  to  com- 
plete recovery.  A  second,  third,  and  even  a  seventh  relapse  may 
occur,  as  in  a  case  recorded  by  Pepper.  Organic  lesions  are  not  usually 
left  behind,  unless  they  have  occurred  as  complications;  but  even  in 
ordinary  cases  the  patient  is  left  weak,  anseniic,  and  with  poor  circula- 
tion. 

Spirillum  Obermeieri.  Found  in  the  blood  of  persons  suffering  from 
relapsing  fever  during  the  paroxysms.  They  consist  of  slender,  flexi- 
ble, spiral  or  wavy  filaments  from  16  to  40//  by  0.1//.  Stains  with 
aniline-colors  and  Loffler's  blue  (see  Plate  II.,  Fig.  4,  a). 

Aerobic  and  motile.  Has  not  been  cultivated  on  artificial  media. 
When  injected  into  the  blood  of  men  or  monkeys  produces  typical 
relapsing  fever. 

The  most  frequent  complications  are  on  the  side  of  the  lungs,  kid- 
neys, and  heart.  Lobar  pneumonia  is  the  most  frequent.  The  heart 
becomes  weakened  by  the  very  high  fever  and  thrombosis,  or  sudden 
failure,  results.  Embolism  is  very  frequent.  Suppurative  parotitis, 
abscess  of  the  spleen,  profuse  epistaxis,  abortion  in  pregnant  women, 
and  neuritis  deserve  mention. 

Relapsing  fever  occurs  at  all  ages,  but  is  most  common  in  adults. 

The  duration  varies  according  to  the  number  of  paroxysms.  If 
there  is  only  one,  it  is  about  eighteen  days.  Under  the  name  "  bilious 
typhoid"  a  malignant  form  of  relapsing  fever  has  been  described. 
It  is  characterized  by  intensity  of  the  symptoms  of  the  ordinary  form, 
and  by  bilious  or  bloody  vomiting,  jaundice,  and  delirium,  or  by  col- 
lapse, with  purple  nose,  a  small,  frequent  weak  pulse,  rigidity  of  the 
abdominal  muscles,  tenderness  in  the  epigastrium,  and  cold,  clammy 
skin.  In  some  of  the  cases  described  by  Graves  intussusception  of  the 
intestines  was  found  after  death.  In  other  cases  uraemia  is  an  active 
factor. 

Diagnosis.  The  earlier  cases  in  an  epidemic  may  not  be  recognized, 
unless  the  blood  be  examined,  until  the  occurrence  of  the  characteristic 
relapse.  It  is  most  likely  to  be  mistaken  for  typhus  fever,  which  occurs 
under  similar  conditions.  The  aspect  of  the  two  diseases  is  very  dif- 
ferent. In  typhus  there  is  a  heavy,  stupid,  sometimes  besotted  expres- 
sion, with  slight  redness  of  the  eyes  and  a  contracted  pupil.  The 
patient  lies  oblivious  of  his  surroundings,  with  low  muttering  delirium 
and  ataxic  symptoms.  In  relapsing  fever,  on  the  other  hand,  the  sen- 
sorium  is  rarely  much  disturbed,  the  spleen  and  liver  are  enlarged,  and 
there  is  hyperesthesia.  Moreover,  in  typhus  there  is  a  spotted  erup- 
tion, later  becoming  petechial.     In  relapsing  fever  this  is  absent. 


n0 


786  SPECIAL  DIAGNOSIS. 

Variola. 

Variola,  or  smallpox,  is  a  specific  infectious  and  contagions  fever, 
beginning  abruptly  with  chill,  high  temperature,  headache,  vomiting, 
sweating,  and  intense  pain  in  the  back.  On  the  second  or  third  day  of 
the  disease  a  characteristic  shot-like,  papular  eruption  appears,  the  pap- 
ules rapidly  developing  first  into  vesicles  and  then  into  pustules;  with 
the  appearance  of  the  rash  the  temperature  falls,  but  rises  again  toward 
the  end  of  the  week  in  the  pustular  stage  (fever  of  maturation  or  sup- 
puration). The  contents  of  the  pustules  are  discharged,  crusts  form 
and  are  cast  off  about  the  eighteenth  day.  The  disease  may  be  accom- 
panied by  a  number  of  complications,  particularly  hemorrhages  into 
the  skin  (purpuric  smallpox)  and  from  the  mucous  membranes  (hem- 
orrhagic smallpox),  both  forms  being  popularly  called  black  smallpox. 
For  convenience  of  description  the  disease  may  be  divided  into  four 
stages:  (1)  Incubation,  (2)  invasion,  (3)  eruption,  (4)  desquamation.  _ 

Incubatiox.  This  stage  lasts  from  ten  to  fourteen  days,  and  is 
usually  unaccompanied  by  any  symptoms  except,  toward  its  close,  by 
malaise. 

Invasion  is  abrupt,  and  is  marked  by  chilliness  or  a  distinct  rigor, 
headache,  severe  pain  in  the  lumbar  region,  and  sometimes  delirium  or 
convulsions,  especially  in  children.  The  most  prominent  symptoms 
are  the  excruciating  headache  and  backache.  The  temperature  usually 
rises  rapidly  to  104°  F.  or  higher  in  the  first  twenty-four  or  forty- 
eight  hours.  Headache  and  backache  continue;  there  are  pain  in  the 
epigastrium,  a  coated  tongue,  loss  of  appetite,  nausea  or  vomiting,  con- 
stipation, and  copious  perspiration.  Prostration  is  extreme.  Erythe- 
matous eruptions  are  not  uncommon,  especially  on  the  inner  surfaces 
of  the  legs  and  thighs.  Petechias  are  found  in  Simon's  triangle,  the 
base  of  which  is  at  the  umbilicus  and  apex  at  the  knees. 

The  stage  of  invasion  lasts  generally  three  days  ;  but  it  may  be  short- 
ened to  two  in  very  severe  cases  or  lengthened  to  four  in  very  mild 
ones,  and  in  complicated  and  hemorrhagic  cases  it  merges  into  the 
stage  of 

Eruption.  The  characteristic  eruption  of  smallpox  appears  first 
as  minute  specks  resembling  fleabites.  These  in  two  or  three  days 
develop  into  small  papules  which  feel  like  shot  under  the  skin.  In  a 
day  or  two  more  the  papules  become  vesicles,  at  first  containing  a  clear 
fluid,  which,  however,  rapidly  becomes  turbid;  they  are  umbilicated. 
In  the  course  of  another  day  or  two  the  vesicles  have  become  pustules 
and  are  globular  in  shape.  The  period  of  ripening  or  maturation,  when 
pustulation  is  at  its  height,  lasts  about  three  days;  it  is  characterized 
by  a  marked  secondary  fever,  the  temperature  rising  as  high  as,  or 
higher  than,  in  the  onset  of  the  disease.  The  pustules  now  begin  to 
dry  up  (desiccation)  and  form  dry  scales  or  scabs  which  are  cast  off 
toward  the  end  of  the  third  week  of  the  disease  (eighteenth  day); 
when  the  pustules  have  been  deep  enough  to  involve  the  true  skin,  char- 
acteristic scars,  called  pits,  are  left. 

The  eruption  appears  on  the  forehead,  along  the  margin  of  the  hair, 
and  in  the  scalp,  then  over  the  rest  of  the  face,  especially  about  the 


THE  INFECTIOUS  DISEASES. 


787 


nose  and  lips,  subsequently  progressing  over  the  rest  of  the  body  from 
above  downward.  The  eruption  is  most  abundant  upon  the  face  and 
hands,  often  being  confluent  here  when  discrete  elsewhere.  The  face 
may  appear  horribly  swollen,  bloated,  and  disfigured,  and  both  face  and 
hands  are  extremely  painful  from  the  great  distention  and  the  pustules, 
which  are  really  small  dermal  abscesses. 


Fig.  154. 


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Temperature  in  smallpox.    Adult :  mild  case. 


Varieties.  Three  varieties  of  variola,  depending  upon  the  number 
and  disposition  of  the  pocks  and  upon  the  presence  of  complications, 
are  recognized:  (1)  Discrete;  (2)  confluent;  (3)  malignant. 

In  discrete  variola  the  pocks  are  not  numerous  and  are  separated  from 
each  other  by  intervening  healthy  skin. 

In  confluent  smallpox  the  pustules  are  close-set,  occupy  almost  the 
whole  body,  and  coalesce,  so  that  the  face  looks  as  though  covered  with 
a  black,  rough  mask;  the  mucous  membranes  are  also  covered.  The 
symptoms  of  the  invasion  are  intensified  and  the  eruption  may  appear 
before  the  third  day.  Patients  are  liable  to  suffer  with  profuse  saliva- 
tion, uncontrollable  vomiting,  or  diarrhoea  (especially  in  children),  and 
with  delirium  which  is  often  violent  and  destructive.  The  face  is 
dreadfully  swollen  and  the  eyelids  may  slough;  the  feet  and  limbs  also 
may  be  swollen  and  painful.  There  may  also  be  severe  bronchitis  and 
pneumonia,  abscesses,  extensive  sloughing,  and  a  pyaemic  condition. 

Malignant,  or  black,  smallpox  is  a  form  in  which  the  blood  is  so 
altered  that  hemorrhages  into  the  skin  or  from  the  mucous  membranes 
occur.  ^  In  the  former  case  there  are  petechia?  and  ecchymoses  upon  the 
skin;  in  the  latter  more  or  less  profuse  hemorrhages  occur  from  the 
womb,  kidney,  bowels,  lungs,  and  stomach.  The  mind  of  the  patient 
remains  clear  and  he  is  conscious  of  his  peril.  The  eruption  is  delayed 
or  does  not  occur  at  all. 

Varioloid  is  a  mild  form  of  smallpox  occurring  in  a  person  pro- 
tected, but  not  completely,  by  previous  vaccination,  or  in  a  person  who, 


788  SPECIAL  DIAGNOSIS. 

from  other  causes,  does  not  possess  the  average  susceptibility.  It  is 
characterized,  apart  from  its  mildness,  by  great  irregularity  in  the 
development  of  the  symptoms.  The  initial  symptoms,  as  a  rule,  are 
as  severe  as  in  ordinary  smallpox.  Prodromal  eruptions,  especially  the 
erythematous,  are  very  common.  The  eruption  may  appear  first  on 
the  face,  or  on  the  chest  and  trunk  first,  and  later  upon  the  face.  The 
fever  subsides  with  its  appearance.  The  eruption  passes  from  the  pap- 
ular to  the  vesicular  stage,  as  in  ordinary  smallpox;  but  here  the  pro- 
cess, as  a  rule,  ceases,  the  vesicle  drying  up  on  the  fifth  or  sixth  day 
of  the  eruption.  If  pustules  form,  they  do  not  reach  their  full  devel- 
opment. The  eruption  is  always  discrete.  There  is  usually  no 
secondary  fever. 

Diagnosis.  When  fully  developed,  smallpox  will  not  be  mistaken 
for  any  other  disorder.  In  the  initial  stage,  however,  there  may  be 
doubt  whether  the  disease  will  prove  to  be  pneumonia,  cerebro-spinal 
meningitis,  or  typhus.  If  the  patient  has  been  exposed  to  smallpox 
and  is  unprotected  by  vaccination,  and  he  is  suddenly  seized  with  a 
chill,  high  temperature,  and  excruciating  pain  in  the  lumbar  region, 
there  is  great  probability  in  favor  of  smallpox.  If  the  patient  has 
complained  of  headache,  pains  in  the  ankles  and  other  joints,  and  is 
seized  with  a  severe  rigor,  explosive  vomiting,  and  great  weakness  of 
the  limbs,  the  chances  favor  meningitis  in  the  absence  of  known  expo- 
sure to  smallpox.  In  pneumonia,  vomiting,  chill,  and  high  tempera- 
ture succeed  each  other,  but  excruciating  backache  is  wanting,  and,  on 
the  other  hand,  the  respiration  is  increased  out  of  proportion  to  the  pulse, 
and  even  in  this  early  stage  there  may  be  cough  and  roughening  of  the 
respiratory  murmur  on  one  side. 

Typhus  fever  begins  abruptly  with  chill  and  high  temperature;  but 
the  eruption  which  comes  out  on  the  fourth  or  fifth  day  is  first 
macular  and  later  petechial,  the  temperature  does  not  fall  with  the 
appearance  of  the  eruption,  the  aspect  of  the  patient  is  drunken  and 
stuporous,  the  conjunctivae  are  injected,  the  eye  ferret}",  the  skin  dry, 
hot,  and  biting  to  the  touch  (calor  mordax). 

In  the  papular  stage  of  the  eruption  it  may  be  mistaken  for  measles ; 
but  the  red,  swollen,  blear-eyed,  photophobic  little  patient  with  measles, 
with  the  characteristic  coryza  and  obstinate  cough,  presents  a  very  dif- 
ferent appearance  from  that  seen  in  variola.  Moreover,  the  eruption 
of  measles  is  relatively  flat,  smooth,  and  velvety;  that  of  smallpox  is 
acuminate,  hard,  and  shot-like.  The  temperature  in  smallpox  falls  as 
the  eruption  appears;  that  of  measles  remains  high  and  even  increases. 
The  papules  of  measles  do  not  develop  into  vesicles.     . 

In  the  vesicular  stage  varioloid  may  be  mistaken  for  chicken-pox. 
In  the  latter  the  eruption  is  practically  vesicular  from  the  start,  occurs 
without  prodromata,  appears  first  upon  the  chest  and  neck,  later  upon 
the  face  and  scalp,  is  usually  very  scanty,  and  rarely  becomes  umbili- 
cated  or  pustular.  There  are,  however,  severe  forms  of  varicella  in 
which  fever,  restlessness,  and  cough  precede  the  appearance  of  the 
rash,  which  is  copious,  some  of  the  vesicles  being  inflamed  at  the  base, 
some  umbilicated,  and  some  with  purulent  contents.  These  cases  are 
most  common  in  scrofulous  children  whose  hygienic  surroundings  are 


THE  INFECTIOUS  DISEASES.  789 

bad.  In  such  cases  the  diagnosis  cannot  be  made  from  the  eruption. 
A  consideration  of  the  following  points  must  decide:  1.  History  of 
exposure  to  varicella,  on  the  one  hand,  or  smallpox  on  the  other.  2. 
The  presence  or  absence  of  effective  vaccination.  3.  The  age  of  the 
patient :  smallpox  occurs  at  all  ages,  varicella  only  in  childhood.  4. 
The  discovery  among  neighboring  children  of  unmistakable  varicella 
or  varioloid. 

Varicella. 

Chicken-pox  is  an  acute  specific  infectious  fever,  occurring  almost 
exclusively  in  children,  and  characterized  by  the  appearance,  in  suc- 
cessive crops,  of  colorless  or  pearly  vesicles,  which  dry  up  and  are  shed 
in  from  two  to  five  days.  It  is  attended  with  very  little  constitutional 
disturbance. 

The  incubation  is  generally  about  two  weeks,  but  may  be  one  or  three 
weeks.  In  ordinary  cases  the  first  evidence  of  the  invasion  of  the  dis- 
ease is  the  appearance  of  the  eruption.  In  other  cases,  the  severer 
ones,  the  child  may  be  noticed  for  some  hours  or  several  days  to  be 
indisposed,  complaining  of  loss  of  appetite,  nausea,  headache,  and 
vague  muscular  pains.  The  fever  is  almost  always  moderate — 100° 
to  101°. 

The  eruption  consists  first  of  hypersemic  macules,  compared  by  Trous- 
seau to  the  rose-rash  of  typhoid  fever.  These  macules  rapidly  become 
first  papules  and  then  vesicles.  The  papules  are  not  hard  as  in  variola. 
They  appear  first  upon  the  chest,  neck,  face,  and  scalp,  then  upon 
the  trunk  and  limbs.  The  development  of  the  vesicles  is  so  rapid  that 
the  eruption  appears  vesicular  from  the  start.  The  vesicles  vary  in 
size  from  a  pinhead  to  a  small  pea.  They  are  very  superficial,  and 
usually  rest  upon  a  base  that  is  slightly  or  not  at  all  hyperamiic.  The 
contents  are  at  first  watery,  but  subsequently  become  pearly.  The 
reaction  of  the  fluid  is  alkaline.  Distinct  umbilication  is  rare,  and  pus- 
tulation  still  more  rare,  but  both  occur.  Almost  always  the  vesicles  dry 
up  and  form  scabs,  yellowish  or  brownish,  which  drop  off,  leaving  a 
slightly  reddened,  sometimes  depressed  spot.  Sometimes  the  vesicles 
are  to  be  seen  upon  the  buccal  mucous  membrane  and  upon  the  throat. 
While  most  of  the  eruption  appears  on  the  first  or  second  day,  fresh 
vesicles  continue  to  appear  for  several  days. 

Desiccation  usually  occurs  by  the  fourth  or  fifth  day,  and  may  be 
present  in  the  first  day  or  two.  As  the  eruption  appears  in  successive 
crops,  often  all  stages,  from  the  initial  macule  to  the  dried  scales,  can 
be  seen  in  one  case. 

Usually  the  vesicles  are  widely  scattered,  a  dozen  or  two  over  the 
entire  body.  They  are  most  numerous  upon  the  back,  and  may  be  as 
close  together  as  in  discrete  variola. 

In  scrofulous  and  badly  nourished  children  the  lesions  arc  more 
inflammatory  and  pustules  are  more  common.  If  they  are  scratched, 
ulceration  ensues.  A  gangrenous  form  has  been  described  by  Eustace 
Smith  and  others;  the  cases  are  apt  to  be  fatal. 

In  ordinary  eases  during  the  eruption  the  child  is  rarely  more  than 
indisposed;  complications  are  rare,  and  the  proguosis  most  excellent. 


790  SPECIAL  DIAGNOSIS. 

The  physician  is  not  often  consulted  except  to  have  his  opinion  as  to 
the  diagnosis.  (For  the  differential  diagnosis  from  smallpox,  see 
Variola.) 

From  vesicular  and  pustular  eczema  it  is  distinguished  by  the  fever, 
the  symmetrical  grouping  and  discrete  character  of  the  lesions,  the  com- 
parative absence  of  itching  and  burning,  and  its  shorter  course. 

Impetigo  is  distinguished  by  the  absence  of  fever,  the  more  local 
character  of  the  eruption,  and  the  fact  that  it  is  generally  pustular. 
It  is  more  common  upon  the  face  and  hands  than  is  varicella. 

Measles. 

An  acute  specific  infectious  and  highly  contagious  fever,  character- 
ized by  coryza  and  bronchitis,  a  red  papular  eruption,  coming  out  on 
the  fourth  day  and  followed  by  a  branny  desquamation  about  the  ninth 
or  tenth  day.  The  mucous  membranes  are  especially  liable  to  compli- 
cations. 

Measles  occurs  in  epidemics,  especially  in  cold  weather,  but  indi- 
vidual cases  are  met  with  in  large  cities  at  all  seasons  of  the  year.  It 
is  so  contagious  that  when  one  case  develops  in  a  household  or  institu- 
tion almost  every  person  exposed  to  it  and  not  protected  by  a  previous 
attack  acquires  it.  Children  from  one  to  five  years  of  age  are  most 
susceptible  to  the  poison,  but  it  may  occur  in  utero  and  in  old  age; 
moreover,  the  same  person  may  have  several  attacks,  showing  that  one 
attack  does  not  afford  the  same  protection  as  an  attack  of  scarlatina  or 
variola. 

Measles  is  sometimes  found  in  association  with  scarlatina  and  vari- 
cella, but  it  is  especially  liable  to  occur  after  pertussis. 

The  specific  cause  of  the  disease  has  not  yet  been  isolated. 

The  period  of  incubation  lasts  from  eleven  to  fourteen  days.  During 
this  time  the  patient  may  exhibit  no  symptoms,  or  may  be  irritable  and 
restless,  with  disturbed  sleep  and  occasional  cough,  and  looseness  of 
the  bowels. 

The  invasion  is  marked  by  cough  and  fever,  and  by  redness  of  the 
eyes  and  lacrymation,  sometimes  with  photophobia,  sneezing,  and  an 
irritating,  watery  discharge  from  the  nose,  which  subsequently  becomes 
muco-purulent,  and  by  cough  and  fever.  In  short,  the  early  symp- 
toms are  those  of  a  severe  coryza.  These  symptoms  last  from  three  to 
five  days  (generally  four)  before  the  eruption  appears.  But  the  erup- 
tion is  commonly  visible  upon  the  base  of  the  uvula  and  soft  palate, 
as  raised,  discrete  dark-red  papules,  several  days  before  it  appears 
upon  the  body.  The  temperature  rises  during  the  first  day  to  100°  or 
102°,  or  higher,  if  the  case  is  to  be  a  severe  one.  The  bowels  are  fre- 
quently inclined  to  be  loose  and  the  passages  somewhat  greenish.  The 
temperature  falls  on  the  second  clay  to  normal  or  nearly  normal,  and 
then  steadily  rises  until  it  reaches  its  acme  with  the  full  development 
of  the  eruption,  when,  in  uncomplicated  cases,  it  falls  rapidly  to  nor- 
mal. With  the  coming  out  of  the  eruption  the  coryza  increases  in 
severity,  and  cough  is  a  prominent  and  annoying  symptom.  It  con- 
sists of  a  series  of  five  or  six  explosive  efforts  without  expectoration. 


THE  INFECTIO  US  DISEASES. 


791 


In  severe  cases  the  cough  is  almost  incessant,  so  that  rest  is  much 
interfered  with.  It  depends  upon  a  catarrhal  inflammation  of  the 
entire  respiratory  tract,  from  the  nose  to  the  bronchioles. 


Fig.  155. 


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Measles.    Temperature  taken  on  the  first  day 
made  higher  as  the  result  of  school  and  exertion. 


Measles.  Lower  temperature  second  and 
third  days.  Hyperpyrexia  sixth  day.  Abun- 
dant eruption.    Bronchitis  severe. 


Objective  Symptoms.  The  eruption  on  the  body  appears  first  about 
the  neck,  face,  and  wrists,  and  spreads  in  two  or  three  days  over  the 
entire  body.  It  is  usually  most  copious  upon  the  face,  which  is  swol- 
len, dark-red  in  color,  and  closely  set  with  papules,  which  are  elevated, 
rounded  at  the  summits,  and  feel  like  soft  velvet  to  the  touch.  When 
to  this  picture  is  added  that  of  a  severe  coryza  with  muco-serous 
exudate,  which  often  glues  the  eyelids  together  and  oozes  out  upon 
the  face,  and  a  corresponding  condition  of  the  nasal  orifices,  the 
physiognomy  is  at  once  seen  to  be  very  unusual.  At  this  stage,  more- 
over, photophobia  is  often  considerable,  the  child  burrowing  its  head 
in  the  pillows  to  escape  light. 

The  eruption  is  not  apt  to  be  confluent  upon  the  body;  here  the  dark- 
red,  elevated,  smooth  papules  are  very  distinct.  Sometimes  they  are 
grouped  so  as  to  form  crescentic  outlines.  The  eruption  fades  in  the 
order  in  which  it  appeared,  and  is  followed  by  a  fine  branny  desqua- 
mation. With  the  completion  of  the  eruption  the  fever  falls  rapidly 
to  or  below  normal,  the  coryza  and  bronchitis  improve  correspondingly, 
and  in  forty-eight  hours  convalescence  is  fully  established. 

Complications.  The  complications  of  measles  affect  for  the  most  part 
the  mucous  membranes  of  the  respiratory  and  digestive  tracts.  The 
bronchitis,  which  is  always  present,  may  become  capillary,  or  be  asso- 
ciated with  oedema  or  with  areas  of  catarrhal  pneumonia.  These  arc  the 
most  frequent  and  the  most  dangerous  complications.  Pneumonia  may 
develop  while  the  eruption  is  coming  out)  in  which  case  the  eruption  is 
delayed  or  the  spots  have  a  dusky  or  bluish  hue  (black  measles).     More 


792  SPECIAL  DIAGNOSIS. 

commonly,  perhaps,  pneumonia  is  discovered  when,  the  eruption  being 
complete,  a  crisis  should  occur. 

Epistaxis  is  not  usually  dangerous.  Profuse  diarrhoea  is  very  ex- 
hausting and  delays  the  evolution  of  the  eruption.  Severe  conjunc- 
tivitis, sometimes  with  ulceration  of  the  cornea,  is  not  uncommon. 
Otitis  media  occurs  oftener  as  a  sequel  than  as  a  complication.  Xoma, 
or  cancrum  oris,  is  a  rare  complication  of  measles  occurring  in  ill-fed, 
badly  nourished  children.      It  is  frequently  fatal. 

Convulsions  may  occur  as  a  complication,  especially  when  pneumonia 
is  developing. 

Sequelce.  In  cases  in  which  there  has  been  diarrhoea,  measles  is  some- 
times followed  by  considerable  weakening  of  the  digestive  power.  The 
catarrh  of  the  respiratory  tract,  which  almost  invariably  accompanies 
it,  predisposes  to  the  development  of  whooping-cough  and  tuberculosis. 

Paralysis  may  follow  measles.  It  may  be  central  or  peripheral  in 
origin,  but  generally  is  of  the  hemiplegic  type;  cases  of  acute  polio- 
myelitis, acute  ascending  paralysis,  and  disseminated  myelitis  have  also 
been  reported. 

Varieties.  Measles  without  catarrh  is  rare.  It  cannot  be  recognized 
from  a  measles-like  rash,  seen  in  rotheln,  except  by  the  occurrence  in 
the  neighborhood  of  other  cases  of  undoubted  measles. 

Measles  without  eruption  is  to  be  recognized  by  the  coryza,  possibly 
with  eruption  on  the  soft  palate,  the  course  of  the  temperature,  and 
the  exposure  to  specific  infection. 

Black  measles  is  the  name  given  to  malignant  forms  in  which,  owing 
to  complications,  particularly  pneumonia,  the  skin  is  dusky  and  the 
eruption  comes  out  poorly  and  has  a  bluish  color.  In  rare  instances 
the  eruption  shows  a  hemorrhagic  tendency,  the  spots  being  livid  or 
ecchymotic.  '  Actual  hemorrhages  from  mucous  surfaces  may  occur, 
the  patient  dying  in  coma  or  convulsions. 

Scarlatina. 

An  acute,  specific,  contagious  and  infectious  fever,  characterized  by 
a  sudden  onset,  with  vomiting,  sore-throat,  and  high  fever,  followed 
in  twelve  or  twenty-four  hours  by  a  bright-red,  punctiform  eruption, 
by  a  very  frequent  pulse,  by  a  desquamation  which  is  often  in  large 
flakes,  by  a  very  variable  degree  of  severity  and  by  a  large  number  of 
complications  and  sequelce,  especially  nephritis  and  inflammation  of 
serous  membranes. 

Scarlet  fever  preferably  affects  children  from  one  to  five  years  of 
age.  The  liability  to  it  diminishes  after  the  tenth  year;  but  it  is  very 
rare  under  the  age  of  six  months.  Puerperal  women  are  very  suscep- 
tible to  the  poison,  and  the  existence  of  open  wounds  favors  infection. 
The  disease  occurs  in  epidemics  at  longer  intervals  than  is  true  of 
measles.  Cases  are  most  numerous  in  the  autumn  and  winter  months. 
The  peculiar  poison  is  doubtless  a  living  organism,  but  it  has  not  been 
isolated  as  yet.  It  is  very  tenacious  of  life,  being  capable  of  infecting, 
through  clothing  in  which  it  has  been  retained,  months  after  the  cloth- 
ing absorbed  the  poison. 


THE  INFECTIO  US  DISEASES. 


793 


Few  diseases  vary  so  greatly  in  severity  in  different  cases  and  in 
different  epidemics.  It  may  be  the  mildest  or  the  most  malignant  of 
diseases. 

The  period  of  incubation  is  remarkably  short,  generally  from  three 
to  five  days;  but  it  may  be  a  few  hours,  and,  in  exceptional  cases,  six 
days. 

Fig.  157. 


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Scarlet  fever.    Mild  attack  ;  intense  eruption. 


The  invasion  is  abrupt.  It  is  very  common  to  be  told  that  a  child 
was  apparently  well  on  going  to  bed,  but  awoke  in  the  middle  of  the 
nio-ht,  vomited  profusely,  and  complained  of  sore-throat.  The  child 
is  found  in  the  morning  with  a  temperature  of  103°  or  104°,  a  pulse  of 
120  to  140,  and  a  scarlatinal  eruption  beginning  to  show  upon  the  neck 
and  upper  part  of  the  chest.  Closer  observation  in  such  cases  might 
have  discovered  that  the  child  was  feverish  on  going  to  bed,  and  that 
he  had  been  somewhat  chilly  before  that.  Onset  with  decided  chill, 
vomiting,  and  nervous  symptoms  indicates  a  severe  case. 

The  subjective  symptoms  of  scarlatina  are  few;  they  consist  usually 
of  pain  in  swallowing,  with  stiffness  of  the  neck-muscles,  some  head- 
ache, thirst,  malaise,  and  a  moderate  amount  of  weakness.  In  the 
eruptive  stage  the  skin  itches,  burns,  and  is  frequently  hypersesthetic. 

The  objective  symptoms  and  their  order  of  succession  are  very  char- 
acteristic. Vomiting  is  the  rule,  except  in  mild  cases,  and  hence  is  of 
importance  in  diagnosis,  especially  in  otherwise  doubtful  cases.  The 
temperature  is  high  at  the  onset,  frequently  103°  or  104°.  It  falls  a 
degree  or  so  in  the  morning;  but  the  following  evening,  when  the 
eruption  is  usually  at  its  height,  it  rises  to  104°  or  105°,  and  then 
gradually  falls  to  normal  in  the  course  of  a  week,  in  ordinary  cases. 
(Figs.  7  and  157.) 

The  pulse-rate  is  characteristically  frequent,  being  120  to  160  oftener 
than  slower.      This  frequency  is  not  an  indication  of  danger. 

The  throat  exhibits  a  uniform  flush  extending  over  pharynx,  tonsils, 
soft  palate,  and  sometimes  forward  on  the  hard  palate,  nearly  to  the 


794  SPECIAL  DIAGNOSIS. 

teeth.  Sometimes  dark-red  points  can  be  distinguished  on  the  soft 
palate.  The  tonsils  are  inflamed  and  project  toward  the  median  line 
from  each  side.  Frequently  the  mouths  of  the  follicles  are  blocked  by 
a  creamy-white  exudate.  It  is  not  uncommon  to  find  a  severe  follicular 
tonsillitis  at  the  first  visit. 

The  tongue  is  at  first  covered  with  a  thick,  creamy  fur,  through 
which  enlarged  red  papilla?  show.  The  coating  soon  disappears  from 
the  tip,  leaving  it  bright  red — the  "  strawberry  tongue." 

The  skin  is  hot  and  dry.  The  characteristic  eruption  usually  appears 
within  twenty-four  hours,  often  within  six  to  eighteen  hours,  of  the 
chilliness  or  vomiting  which  marks  the  onset.  Sometimes  it  comes 
out  very  slowly,  seeming  to  be  just  ready  to  appear,  but  not  appearing 
in  its  full  development  ior  four  or  five  days. 

The  intensity  of  the  eruption  varies  from  a  scarcely  perceptible 
erythema  to  the  color  of  a  boiled  lobster.  Usually  its  intensity  varies 
with  the  severity  of  the  disease.  In  ordinary  cases  the  patient  appears 
to  be  covered  with  a  uniform  red  efflorescence;  but  a  closer  inspection 
shows  that  there  are  darker  red  spots  between  which  the  skin  is  more 
or  less  erythematous.  It  is  first  seen  about  the  ears  and  neck,  and 
spreads  with  great  rapidity,  covering  the  entire  body  in  a  day.  It  is 
most  intense  upon  the  trunk  and  flexor  surfaces.  Upon  the  extensor 
surfaces  the  punctate  character  is  better  seen.  Pressure  causes  the 
redness  to  disappear,  but  it  immediately  reappears.  Papular  and 
vesicular  forms  of  eruption  are  also  seen.  The  physiognomy  of  the 
disease  is  peculiar.  The  circle  about  the  eyes,  nose,  and  lips  remains 
pale,  while  the  rest  of  the  face  may  be  fiery  red.  Itching  and  burning 
are  annoying  symptoms  at  times  The  eruption  fades  gradually,  in 
ordinary  cases  disappearing,  except  when  there  is  pressure  or  irritation, 
toward  the  end  of  the  week. 

The  eruption  is  succeeded  by  desquamation,  which  is  extensive  in 
proportion  to  the  intensity  of  the  eruption.  The  flakes  are  larger  than 
in  measles,  and  in  severe  cases  the  epidermis  may  come  off  in  long  strips. 
About  the  hands  and  feet  this  shedding  is  sometimes  so  great  as  to 
be  compared  to  a  glove.  This  stage  may  be  protracted  for  several 
weeks,  clanger  of  infection  lasting  as  long  as  desquamation  continues. 

The  urine  is  at  first  scanty,  high-colored,  and  febrile.  Later,  when 
desquamation  is  in  progress,  there  is  great  liability  to  albuminuria  as 
a  complication. 

Varieties.  In  addition  to  the  ordinary  form  already  described  scar- 
latina exhibits  many  irregular  forms.  There  may  be  only  a  sore-throat 
or  follicular  tonsillitis.  If  a  rash  is  present,  it  is  very  faint,  and  hence 
easily  overlooked.  The  diagnosis  in  such  cases  must  be  made  from  the 
fact  of  exposure  to  infection  and  from  the  appearance  of  the  throat. 
The  occurrence  of  vomiting  is  very  important  in  the  diagnosis,  as  it  is 
rare  in  ordinary  pharyngitis  and  tonsillitis.  Often  such  cases  altogether 
escape  detection,  until  possibly  a  dropsy  from  scarlatinal  nephritis 
indicates  their  nature. 

Severe  diarrhoea  may  prevent  the  eruption  from  developing  upon  the 
skin.  It  appears  upon  the  fauces,  and  the  diagnosis  is  based  upon 
this,  the  pulse  and  temperature,  and  the  fact  of  exposure. 


THE  1NFEGTI0  US  DISEASES.  795 

In  scarlatina  anginosa  the  strength  of  the  poison  is  spent  upon  the 
throat.  Pain  is  great  and  deglutition  difficult.  The  tonsils  are  greatly 
swollen,  so  as  almost  to  occlude  the  fauces,  and  their  surfaces  are  cov- 
ered with  creamy  exudate.  The  cervical  glands  are  swollen  and  there 
is  a  tense  and  brawny  cellulitis.  Sometimes  the  tonsils  become  gan- 
grenous, and  the  cervical  or  submaxillary  glands  suppurate  or  become 
gaugrenous,  with  resulting  pyaemia  and  death.  Suppuration  may 
extend  to  the  ears  and  maxillary  sinuses.  In  this  form,  also,  a  false 
membrane  is  sometimes  found  upon  the  fauces — post-scarlatinal  diph- 
theria. It  is  probably  not  due  to  the  Klebs-Lbfner  bacillus,  but  to  a 
streptococcus. 

In  malignant  forms  the  attack  is  ushered  in  with  chill,  followed  by 
hyperpyrexia,  convulsions,  marked  ataxic  symptoms,  or  stupor.  The 
profound  blood-disturbance  is  shown  by  the  dusky  hue  of  the  eruption. 
Some  patients  lie  in  coma-vigil,  others  are  very  restless  and  delirious. 
Vomiting  and  diarrhoea  are  sometimes  superadded.  Patients  may 
emerge  from  this  condition  and  succumb  later  to  a  nephritis  or  to  grave 
anginose  symptoms;  but  death  in  a  few  days  is  the  rule.  In  rare  cases 
the  dose  of  poison  is  so  enormous  that  death  takes  place  in  a  few  hours, 
without  the  appearance  of  any  eruption. 

Complications  and  Sequelce.  The  severe  local  symptoms  mentioned 
under  the  anginose  variety,  together  with  convulsions,  hyperpyrexia, 
and  ataxic  symptoms,  may  properly  be  regarded  as  complications. 
Apart  from  these  the  most  frequent  are  nephritis  and  endocarditis  or 
pericarditis.  Nephritis  generally  appears  with  the  beginning  of  des- 
quamation. It  is  nearly  as  frequent  in  mild  as  in  severe  cases,  prob- 
ably because  the  danger  of  exposure  to  cold  is  greater  in  the  former, 
although  the  scarlatinal  poison  unquestionably  has  a  selective  affinity 
for  the  epithelium  of  the  kidney.  The  symptoms  do  not  differ  from 
those  of  acute  parenchymatous  nephritis  occurring  under  other  circum- 
stances. In  some  cases  we  have  weakness,  languor,  slight  fever,  and 
prolonged  convalescence;  in  others,  oedema,  anuria,  convulsions  or 
coma  from  uraemia.  Endocarditis  is  often  preceded  by  tenderness  and 
soreness  of  the  muscles  and  joints — scarlatinal  rheumatism. 

Endocarditis  and  pericarditis  develop  in  the  course  of  the  fever, 
giving  rise  to  an  increase  or  continuance  of  the  fever,  to  local  pain  or 
dyspnoea,  and  to  the  usual  physical  signs. 

Pleuritis  and  meningitis  also  may  occur.  Much  more  common  corn- 
pi  irations  are  otitis,  peripheral  neuritis,  and  affections  of  the  joints, 
grouped  as  scarlatinal  rheumatism.  Paralyses,  peripheral  and  central 
in  origin,  are  occasional  sequels  of  the  disease.  Scarlatina  is  found 
also  in  association  with  other  diseases. 

Diagnosis.  Sudden  onset,  rapid  rise  of  temperature,  persistent 
vomiting,  and  sore-throat  lead  oue  to  suspect  this  affection.  The  char- 
acteristic eruption  and  its  mode  of  evolution,  the  rapid  pulse,  the 
peculiar  tongue,  the  circle  of  pallor  on  the  face,  are  characteristic  of 
the  eruptive  stage.  The  desquamation  is  an  important  diagnostic  fea- 
ture. Scarlet  fever  is  distinguished  from  measles  by  the  mode  of  onset,. 
which  is  sudden,  with  chilliness,  high  temperature,  vomiting,  and  sore- 
throat,  and  great  rapidity  of  the  pulse;  whereas  the  onset  in  measles 


796  SPECIAL  DIAGNOSIS. 

is  gradual,  with  coryza,  cough,  moderate  fever,  perhaps  looseness  of 
the  bowels,  but  no  sore-throat.  The  eruption  of  scarlatina  occurs  on 
the  first  day,  that  of  measles  on  the  fourth  ;  the  former  consists  of 
dark-red  spots  with  intervening  erythematous  skin,  the  whole  looking 
at  a  distance  like  a  uniform  bright-red  flush ;  the  latter  consists  of  raised, 
rounded,  or  flattened  spots  or  blotches,  velvety  to  the  touch,  and,  upon 
the  body  and  extremities,  grouped  in  patches  with  crescentic  outlines. 
The  temperature  in  scarlatina  subsides  gradually  after  the  rash  has 
reached  its  height;  that  of  measles  increases  until  the  eruption  is  com- 
plete, then  subsides  by  crisis.  The  rash  of  scarlet  fever  persists  for 
six  or  eight  days;  that  of  measles  fades  as  soon  as  it  is  complete,  on 
the  fourth  day.  In  the  former,  desquamation  is  in  flakes  or  large 
strips;  in  the  latter  it  is  branny  and  nearly  invisible.  Scarlatina 
involves  by  preference  the  serous  membranes  and  kidneys;  measles 
the  mucous  membranes  and  lungs. 

Scarlatina  has  to  be  differentiated  from  pharyngitis,  tonsillitis,  and 
digestive  disturbances  attended  with  vomiting,  high  temperature,  and 
occasionally  erythematous  eruptions. 

In  ordinary  pharyngitis  and  tonsillitis  the  redness  is  more  apt  to  be 
confined  to  the  pharynx,  tonsils,  and  arches  of  the  soft  palate;  in 
scarlatina  it  extends  as  a  flush  over  the  soft  and  hard  palate  and  buccal 
surfaces.  In  the  former,  high  temperature,  a  very  frequent  pulse,  and 
vomiting  are  unusual;  in  the  latter  they  are  the  rule. 

The  glands  of  the  neck  also  are  more  apt  to  be  involved  in  the  latter. 

In  acute  gastritis  there  is  usually  a  history  pointing  to  indiscretion 
in  eating,  with  constipation.  The  pulse  is  not  so  frequent  as  to  suggest 
scarlatina,  sore-throat  is  absent,  and  any  erythema  present  lacks  the 
characteristic  dark-red  points,  and  is  not  followed  by  desquamation. 

The  diagnosis  from  rubella  is  difficult  at  times.  It  differs  from  scar- 
latina in  presenting  mild  catarrhal  symptoms,  sneezing,  suffusion  of 
the  eyes,  and  cough,  with  a  relatively  fleeting  eruption.  The  latter 
perhaps  appears  most  frequently  upon  the  back  and  chest.  Often  the 
eruption  is  the  first  thing  noticed  amiss  with  the  child.  It  more  com- 
monly resembles  the  rash  of  measles  than  that  of  scarlatina,  but  when 
it  resembles  the  latter  most  it  is  apt  to  be  discrete  and  of  a  darker  red. 
There  may  be  a  very  intense  rash  without  much  constitutional  disturb- 
ance, the  temperature  being  lower  and  the  pulse  much  slower  than 
would  be  expected  in  a  scarlatina  presenting  the  same  appearance. 
Nausea  may  be  present,  but  vomiting  is  very  rare.  The  post-cervical 
and  post-auricular  glands  are  more  commonly  enlarged  in  rubella  than 
in  mild  scarlatina,  though  this  symptom  is  not  invariable. 

Diphtheria  is  distinguished  by  its  gradual  onset,  patches  of  false 
membrane  developing  upon  the  fauces  early.  In  anginose  scarlet  fever, 
with  severe  follicular  tonsillitis,  the  differential  diagnosis  is  essentially 
the  same  as  between  simple  follicular  tonsillitis  and  diphtheria  (q.  v.). 

In  addition,  the  pulse  and  temperature  have  a  much  higher  range  in 
scarlatina.  The  erythema  of  diphtheria  is  distinguished  from  the 
eruption  of  scarlatina  by  its  fleeting  character  and  the  absence  of 
desquamation. 

Grave  cases  which  begin  with  repeated  vomiting,  convulsions,  deli- 


THE  INFECTIOUS  DISEASES.  797 

rium,  and  insomnia  simulate  meningitis ;  but  a  satisfactory  cause  for 
the  latter  is  lacking,  while  the  excessive  heat  of  the  skin,  sore-throat, 
very  frequent  pulse,  and  early  eruption  clear  up  the  diagnosis. 

So,  also,  the  onset  with  vomiting,  convulsion,  and  high  temperature 
resembles  pneumonia  ;  but  in  the  latter  the  respiration  is  proportion- 
ately more  frequent  than  the  pulse,  with  altered  breath-  and  percussion- 
sounds,  while  sore-throat  and  eruption  are  wanting. 

Rubella. 

Rubella  is  an  acute,  specific,  contagious,  and  infectious  fever,  char- 
acterized by  a  gradual  onset  with  moderate  fever,  sore-throat,  and  slight 
coryza.  The  eruption,  which  appears  without  prodromata,  usually 
resembles  measles  more  than  scarlatina.  The  duration,  however,  is 
shorter  than  measles,  the  disease  milder,  and  complications  are  rare. 

The  disease  is  amply  proved  not  to  be  a  hybrid  of  measles  and 
scarlet  fever.  The  incubation-period  varies  from  one  to  three  weeks, 
but  is  generally  about  two.  As  a  rule,  this  period  is  passed  without 
symptoms. 

The  invasion  is  without  prodromata,  or  none  more  definite  than  lan- 
guor and  indisposition,  the  first  thing  noticed  being  the  eruption.  This 
in  some  cases  consists  of  pale-red,  smooth,  slightly  raised  blotches, closely 
resembling  measles,  but  more  pronounced  on  the  trunk,  and  discrete. 
This  is  probably  a  very  rare  form.  More  commonly  it  consists  of  rose- 
red  macula?  or  papules,  occasionally  confluent  but  usually  discrete,  and 
most  marked  upon  the  trunk.  In  still  other  cases  the  eruption  closely 
resembles  that  of  scarlatina,  differing  chiefly  in  being  a  paler  red  and 
accompanied  by  less  heat  of  skin.  Sometimes  the  eruption  is  circum- 
scribed, as  upon  the  face  or  limbs.  It  is  usually  the  seat  of  consider- 
able itching,  and  this  may  be  the  first  symptom  that  attracts  the 
patient's  attention.  It  will  be  seen  then  that  the  eruption  is  multi- 
form in  character.  Concurrently  with  the  eruption,  there  is  usually 
slight  rise  in  temperature  (100°-101°),  suffusion  of  the  eyes,  with  slight 
lacrymation  and  photophobia,  and  slight  pharyngitis;  nausea  is  not 
uncommon,  but  vomiting  is  very  rare.  Higher  temperatures  have 
been  recorded  in  a  few  cases,  and  so  have  nervous  symptoms  such  as 
delirium  and  convulsions,  but  they  are  chiefly  interesting  as  very  ex- 
ceptional possibilities.  On  the  other  hand,  the  disease  may  run  its 
course  without  any  fever. 

The  eruption  extends  over  the  body  in  twenty-four  to  thirty-six 
hours,  less  rapidly  than  in  scarlatina,  and  pales  much  more  quickly, 
fading  on  the  portions  of  the  body  first  attacked  before  reaching  its 
height  on  the  last,  and  being  completed  in  three  or  four  days.  Some- 
times a  branny  desquamation  succeeds. 

In  addition  to  the  mild  coryza  and  eruption,  the  most  important 
objective  symptom  is  swelling  of  the  cervical  glands,  all  of  them 
being  sometimes  swollen,  especially  those  behind  the  stern o-mastoidj 
the  auricle,  and  along  the  margin  of  the  hair.  This  adenopathy,  how- 
ever cannot  be  relied  upon  exclusively  in  the  differentiation  from  scar- 
latina and  measles. 


798  SPECIAL  DIAGNOSIS. 

Rubella  has  few  complications:  bronchitis,  pneumonia,  and  otitis 
occur  rarely,  and  still  more  rarely  false  membrane  on  the  throat,  and 
albuminuria.  The  prognosis  is  excellent.  It  ends  almost  invariably 
in  recovery,  except  in  very  feeble  children. 


Pertussis. 

Whooping-cough  is  a  specific  catarrhal  inflammation  of  the  respira- 
tory passages,  involving  especially  the  trachea  and  bronchi,  and  char- 
acterized by  paroxysms  of  cough,  which  are  succeeded  by  spasmodic 
closure  of  the  glottis  and  a  peculiar  inspiratory  whoop.  The  disease 
occurs  especially  in  childhood,  is  contagious  and  infectious,  and  is 
sometimes  epidemic.  Whooping-cough  may  be  conveniently  divided 
into  three  periods: 

1.  The  catarrhal  stage. 

2.  The  spasmodic  stage. 

3.  The  stage  of  gradual  subsidence  of  the  disease. 

First  Stage.  The  patient  appears  to  have  an  ordinary  cold.  The 
amount  of  redness  of  the  mucous  membrane  of  the  eyes,  nose,  and 
throat  varies  considerably,  but  there  is  not  much  discharge  from  the 
mucous  surfaces.  The  cough  is  dry,  and  sometimes  a  ringing  quality 
can  be  detected.  The  patient  is  irritable,  has  slight  fever,  diminished 
or  capricious  appetite,  and  restless  sleep.  A  mild  bronchitis  of  the 
larger  tubes  can  be  detected  by  physical  exploration. 

The  cough  gradually  becomes  more  frequent  and  paroxysmal,  the 
eyes  are  red  and  suffused,  and  there  is  a  muco-purulent  discharge  from 
the  nose.  The  face  often  looks  slightly  swollen,  especially  about  the 
upper  part  and  under  the  eyes. 

The  Second  Stage.  Transition  from  the  first  to  the  second  stage  is 
marked  by  the  appearance  of  the  characteristic  whoop.  The  parox- 
ysmal cough  is  made  up  of  a  series  of  rapid  expiratory  efforts,  dimin- 
ishing in  force  and  duration;  when  these  cease,  there  succeeds  a 
prolonged  crowing  inspiration — the  whoop.  There  may  be  only  one 
paroxysm  of  coughing  at  a  time,  but  more  commonly,  and  always  in 
severe  cases,  one  paroxysm  is  succeeded  by  another.  During  the 
coughing  the  child's  eyes  become  suffused,  the  tears  overflow,  and  there 
is  a  discharge  of  serum  or  muco-pus  from  the  nose,  and  of  saliva  and 
bronchial  secretion  from  the  mouth.  The  face  becomes  swollen  and 
dusky.  If  the  child  is  walking  about,  it  catches  some  object  for  sup- 
port during  the  paroxysm;  or,  if  old  enough,  rushes  for  the  water- 
closet  or  a  basin,  because  the  seizure  usually  terminates  in  vomiting. 
The  matters  vomited  consist  of  tenacious  mucus  and  the  contents  of 
the  stomach.  With  the  mucus  there  may  be  streaks  of  blood,  and 
occasionally  there  is  pure  blood.  During  severe  paroxysms,  hemor- 
rhages are  apt  to  occur;  these  are  generally  small  and  most  frequently 
submucous.  In  well-marked  cases,  when  the  disease  has  lasted  some 
time,  the  face  has  a  characteristic  appearance:  it  is  swollen,  sodden, 
and  dusky,  with  dull,  heavy,  red,  and  watery  eyes.  There  is  often 
ulceration  of  the  lingual  freenum. 


THE  INFECTIOUS  DISEASES.  799 

The  number  of  paroxysms  varies  from  two  or  three  to  twenty  or 
thirty  or  more  in  twenty-four  hours,  and  they  are  worse  at  night. 

The  whoop,  while  characteristic,  is  not  present  in  every  case,  being 
absent  especially  in  babies  and  very  young  children.  Sometimes  chil- 
dren have  "  choking  spells"  without  much  coughing  and  without  the 
whoop.  Again,  when  pneumonia  or  measles  occurs  as  a  complication, 
the  whoop  usually  ceases  for  the  time,  but  may  reappear  later. 

Third  Stage.  The  third  stage  is  less  well  defined  than  the  first  two. 
It  may  be  said  to  begin  when  the  nocturnal  exacerbations  become  less 
frequent  and  severe.  The  number  of  paroxysms  during  the  day 
diminishes,  and  vomiting  is  a  less  frequent  accompaniment.  Appe- 
tite begins  to  improve,  and  the  child  begins  to  gain  in  flesh  and  to  pass 
more  restful  nights. 

The  duration  of  the  disease  is  variable.  Ordinarily  it  lasts  from 
six  to  eight  weeks,  but  it  may  be  prolonged  for  several  months.  The 
patient  is  liable,  whenever  he  catches  a  fresh  cold,  to  a  temporary  return 
of  the  spasmodic  cough,  sometimes  with  the  whoop. 

The  great  majority  of  the  cases  occur  before  the  sixth  year,  and 
most  of  these  betweeu  the  second  aud  fourth  years. 

Influenza. 

Influenza  is  a  specific  contagious  febrile  disease,  occurring  in  wide- 
spread epidemics,  having  a  very  short  period  of  incubation,  and  char- 
acterized by  great  prostration,  marked  nervous  symptoms,  and  catarrhal 
inflammation  of  the  respiratory  or  gastro-intestinal  tracts,  or  both. 
There  is  great  liability  to  relapse,  and  to  complications,  which  are 
generally  pulmonary  or  nervous. 

The  disease  generally  begins  with  the  ordinary  symptoms  of  coryza; 
but  the  headache  over  the  eyes  and  root  of  the  nose  is  more  severe  and 
may  be  so  agonizing  as  to  mask  all  other  symptoms.  The  lacryma- 
tion,  rhinitis,  and  tormenting  cough  are  all  usually  worse  than  in  ordi- 
nary coryza.  Physical  weakness,  weariness,  and  depression  of  spirits 
are  almost  invariably  present,  and  they  sometimes  reach  an  extraor- 
dinary degree.  Fever  is  usually  moderate  (100°-102°),  but  may  be 
103°  to  104°  for  several  days,  and  then  gradually  subside.  In  ordi- 
nary cases  the  patient  seeks  relief  first  for  the  headache,  severe  aching 
pain  in  back  and  limbs,  and  extreme  weakness ;  if  these  are  relieved, 
he  is  apt  to  complain  most  of  incessant  racking  cough,  often  due  more 
to  a  tracheitis  than  to  bronchitis.  Nausea  and  vomiting  are  not  uncom- 
mon, especially  in  the  morning,  at  which  time  also  the  patient  frequently 
feels  worse  than  he  does  later  in  the  day.  Sleep  is  broken  and  restless, 
and  may  be  accompanied  by  drenching  perspirations.  Severe  neuralgic 
pains  are  common. 

In  some  cases  the  disease  attacks  the  stomach  and  bowels  especially, 
and  vomiting  with  diarrhoea  are  the  prominent  symptoms.  In  others 
the  predominant  symptoms  are  nervous,  and  great  pain  with  prostra- 
tion masks  any  catarrhal  symptoms.  Torpor  and  delirium  may  be 
present.  Sometimes  a  prolonged  and  severe  attack  of  asthma  marks 
infection  in  susceptible  persons. 


800  SPECIAL  DIAGNOSIS. 

The  duration  of  the  disease  is  from  a  few  days  to  a  few  weeks. 
Convalescence  is  remarkably  tedious,  and  is  characterized  by  persistent 
weakness.  Sweats  are  often  annoying  during  this  time.  The  heart 
often  continues  for  some  time  to  beat  too  frequently  and  to  be  easily 
excited  by  exertion.     Relapses  are  common. 

Diagnosis.  Influenza  in  the  great  majority  of  cases  is  easily  recog- 
nized. In  certain  cases,  however,  it  is  to  be  differentiated  from  'pneu- 
monia, typhoid  fever ,  and  cerebrospinal  meningitis. 

Cases  in  which  the  disease  sets  in  with  a  high  fever  and  marked 
chest-symptoms  are  very  apt  to  be  mistaken  for  pneumonia ;  but  the 
headache  and  prostration  are  more  intense,  while  the  respiration  is  not 
so  frequent.  Sweats  are  common,  and  albumin  and  casts  in  the  urine 
are  by  no  means  rare.  Physical  exploration  shows  that  both  lungs 
are  involved,  though  often  not  to  the  same  degree.  Resonance  is 
impaired,  and  auscultation  shows  moist  crepitant  and  subcrepitant 
rales,  which  seem  to  be  due  to  an  oedematous  condition  of  the  lung- 
tissue,  associated  with  a  diffuse  bronchitis.  A  true  lobar  pneumonia 
is  rarely  present  even  as  a  complication. 

If  diarrhoea  is  one  of  the  symptoms,  typhoid  fever  has  to  be  excluded. 
This  is  extremely  difficult  in  the  first  two  or  three  days.  As  a  rule, 
headache,  backache,  nausea,  and  sleeplessness  are  at  this  time  greater 
in  influenza,  the  spleen  is  not  so  much,  if  at  all,  enlarged,  the  diar- 
rhoea can  be  checked,  and  tenderness  and  pain  in  the  right  iliac  fossa 
are  absent. 

From  cerebrospinal  meningitis  it  can  be  distinguished  by  noting  the 
fact  that  it  begins  with  coryza,  whereas  cerebro-spinal  meningitis  often 
sets  in  with  chill,  vomiting,  and  faintness;  the  headache  in  the  former 
is  usually  frontal,  in  the  latter  occipital  and  accompanied  by  stiffness 
of  the  back  of  the  neck.  Further,  in  cerebro-spinal  meningitis  there 
are  often  swellings  of  the  joints,  delirium  alternating  with  coma,  and 
in  young  subjects  convulsions  are  common. 

Finally,  it  may  be  said  that  the  pronounced  diagnostic  feature  is  the 
preponderance  of  general  symptoms  over  local  inflammations.  The 
occurrence  of  undue  exhaustion,  extreme  general  neuralgias  and  myal- 
gias, and  high  fever,  profuse  sweats,  without  intense  catarrh  or  inflam- 
mation to  account  for  them,  is  of  the  highest  diagnostic  significance. 
The  presence  of  an  epidemic,  the  contagious  nature  of  the  affection, 
the  presence  in  the  discharges  of  the  micro-organisms  described  by 
Pfeiffer,  and  the  sudden  onset,  all  point  to  influenza. 

Mumps. 

Mumps  or  epidemic  parotitis,  is  an  acute,  specific,  contagious  dis- 
ease, characterized  by  a  sudden  onset,  with  great  swelling  and  pain  in 
one  or  both  parotid  glands,  by  short  duration,  and  by  rapid  recovery. 
Orchitis  may  occur  in  boys  over  the  age  of  puberty. 

It  occurs  most  frequently  in  children  under  ten  years  of  age,  but  it 
may  occur  at  any  age.  Males  are  much  more  liable  to  it  than  females. 
Life  in  institutions  or  barracks  appears  to  render  persons  more  suscep- 
tible.    Stomatitis  or  sore-throat  is  said  frequently  to  precede  it. 


THE  INFECTIOUS  DISEASES.  801 

The  period  of  incubation  is  generally  about  two  weeks,  and  is  usually 
free  from  symptoms.  The  invasion  is  sudden,  with  chilliness,  a  rise 
in  temperature  which  is  generally  moderate  (101°-103°),  and  pain  at 
the  angle  of  the  jaw;  the  corresponding  parotid  rapidly  begins  to 
swell,  as  well  as  the  adjacent  cellular  tissue.  The  whole  space  between 
the  ear  and  neck  bulges  out,  the  jaws  are  fixed,  and  any  acid  liquid,  as 
vinegar,  which  stimulates  salivary  secretion,  increases  the  pain.  At 
times  the  submaxillary  glands  are  involved  instead  of  the  parotids. 
The  disease  may  be  limited  to  one  side,  or  involve  the  opposite  side  as 
the  process  in  the  one  first  attacked  subsides.  Rarely  it  is  bilateral 
from  the  start.  When  the  swelling  has  lasted  from  three  to  five  days 
the  fever  subsides,  and  the  swelling  begins  to  disappear  rapidly.  At 
this  time,  however,  the  opposite  side  may  be  attacked,  or  the  testicles 
become  inflamed.  Usually  it  is  the  right  testicle.  In  girls  and  women 
the  ovary  or  mamma  is  rarely  inflamed.  Resolution  is  extremely  rapid, 
and  usually  the  disease  is  not  followed  by  sequelae.  Sometimes,  how- 
ever, deafness  is  left.  In  fact,  sudden  deafness  sometimes  announces 
the  commencement  of  an  attack.  Atrophy  of  the  testicle  is  an  occa- 
sional result  of  the  orchitis. 

Cerebro-spinal  Fever. 

An  acute,  specific,  infectious,  and  mildly  contagious  disease,  sporadic 
and  epidemic,  characterized  by  evidences  of  systemic  infection,  and 
generally  also  by  symptoms  depending  upon  inflammation  of  the  cere- 
bral and  spinal  meninges — particularly  intense  pain  in  the  back  and 
head,  hyperesthesia,  retraction  of  head  and  neck,  delirium,  coma,  and 
convulsions. 

This  disease,  which  is  also  known  as  epidemic  cerebro-spiual  meuin- 
gitis,  and  as  spotted  fever,  is  an  infectious  form  of  meningitis,  in  some 
instances  due  to  the  micrococcus  lanceolatus  (see  page  292).  It  appeared 
in  the  United  States  first  in  1 806.  It  was  epidemic  in  Philadelphia  from 
1863  to  1865,  and  since  then  sporadic  cases  have  been  reported  every  year. 

It  is  most  common  in  cold  weather,  and  in  children  under  fifteen  years 
of  age.  The  period  of  incubation  is  unknown,  but  is  probably  short.  It 
is  free  from  symptoms.  The  invasion  of  the  disease  is  abrupt,  although 
in  some  instances  the  patient  may  complain  of  rheumatoid  pains  in  the 
limbs  or  a  joint,  and  headache  and  weakness.  Usually  the  first  symp- 
tom is  a  severe  chill,  which  may  awaken  the  patient  from  sleep.  In 
other  cases  the  initial  symptom  is  a  convulsion.  Then  quickly  fol- 
low repeated  vomiting,  intense  headache,  sometimes  accompanied  by 
backache,  retraction  of  the  head,  delirium,  and  extreme  prostration, 

The  rise  in  temperature  is  moderate,  and  the  pulse  is  as  often  slow 
as  frequent  (Stillc).  The  face  is  pale  and  livid,  expressing  suffering, 
and  the  patient  may  toss  from  one  side  of  the  bed  to  the  other,  begging 
some  relief  for  his  headache.  The  pain  in  the  back  becomes  more 
severe,  and  root-pains  dart  in  all  directions,  but  especially  into  the 
limbs  or  joints,  which  may  be  swollen  and  tender  to  the  touch;  in 
fact,  the  whole  skin  is  hyperresthetic  and  the  reflexes  are  increased. 
The  spinal  muscles  become  rigid,  and  the  head  is  often  retracted.   Less 

51 


802  SPECIAL  DIAGNOSIS. 

frequently  the  back  is  arched  and  trismus  occurs.  Delirium  is  com- 
mon at  night.  It  is  often  of  a  sportive  type,  the  patient  making 
absurd  remarks,  cracking  jokes,  or  singing  snatches  of  a  comic  song. 
Delirium  may  alternate  with  tonic  or  clonic  convulsions  and  with  stupor. 
The  appetite  is  poor,  the  bowels  constipated.  A  remission  may  occur 
on  the  third  day,  with  temporary  improvement  of  the  symptoms. 

As  the  attack  progresses  there  may  be  strabismus,  which  is  usually 
divergent,  inequality  of  the  pupils,  nystagmus,  ptosis,  and  optic 
neuritis.  Vertigo,  tinnitus,  anosmia,  and  photophobia  are  common. 
Hyperesthesia  and  delirium  persist.  The  pulse  becomes  more  fre- 
quent and  the  fever  continues.  In  favorable  cases  improvement 
now  begins,  the  headache  and  root-pains  abating,  and  delirium  and 
spasms  becoming  less  frequent.  In  unfavorable  cases  the  convul- 
sions may  become  more  severe  and  end  in  fatal  coma,  or  the  patient 
may  sink  into  a  typhoid  condition,  with  nephritis  as  a,  complication. 

The  skin  eruptions,  which  explain  the  name  "  spotted  fever,"  are 
not  always  present  and  exhibit  no  constant  character.  Herpes  labialis 
and  petechia  are  the  most  frequent;  in  other  cases  the  eruption  is  a  pur- 
plish mottling,  or  is  macular,  or  the  eruption  resembles  that  of  measles. 

In  the  malignant  (fulminating)  form  of  the  disease  death  occurs  in  a 
few  hours  or  two  or  three  days.  Such  cases  are  apt  to  arise  early  in  an 
epidemic.  The  patient  has  a  violent  chill;  delirium  occurs  early;  the 
headache  is  less  intense,  or  at  any  rate  gives  way  rapidly  to  stupor  and 
coma.  The  pulse  is  frequent  and  feeble;  there  may  be  no  rise  of  tem- 
perature, the  skin  being  cool,  clammy,  and  cyanotic.  Local  or  general 
convulsions  may  occur.  The  eruption  may  be  purpuric,  and  ecehymoses 
may  even  occur.      The  urine  is  scanty  and  contains  albumin  and  casts. 

Mild  cases  usually  occur  late  in  epidemics.  They  are  characterized 
by  severe  aching  in  the  head,  back,  and  limbs,  nausea,  vomiting,  ver- 
tigo, and  prostration.  They  closely  resemble  the  nervous  type  of  influ- 
enza, and  would  escape  recognition  except  during  an  epidemic. 

An  abortive  form,  ending  in  recovery  in  two  or  three  days,  and  an  inter- 
mittent form,  with  exacerbations  on  alternate  days,  have  been  described. 

The  duration  of  the  disease  is  from  a  few  hours  to  two  or  three 
months.  In  ordinary  favorable  cases  there  is  decided  improvement 
toward  the  end  of  the  first  week,  and  convalescence  is  established  in 
two  weeks.  It  may  become  chronic  and  last  for  weeks,  and,  as  already 
stated,  may  be  fatal  in  a  few  hours.  Relapses  are  common  in  some 
epidemics. 

The  most  frequent  complications  are  on  the  part  of  the  lungs  and 
heart,  particularly  pneumonia  and  endocarditis  or  pericarditis.  Pneu- 
monia often  occurs  so  early  that  it  is  difficult  to  decide  whether  it  is 
primary  with  marked  nervous  symptoms,  or  is  only  a  complication  of 
the  cerebro-spinal  fever.     Nephritis  also  occurs. 

The  most  frequent  sequels  are  deafness,  blindness,  headache,  and  local 
palsies. 

Diphtheria. 

An  acute,  specific,  infectious,  and  contagious  disease,  sporadic  and 
epidemic,  occurring  especially  in  children  from  one  to  six  years  of  age, 


THE  INFECTIO  US  DISEASES.  803 

and  characterized  by  insidious  or  abrupt  onset,  with  moderate  fever, 
and  the  development  upon  the  fauces  or  upon  any  abraded  surface  of 
a  grayish-white  false  membrane,  which  has  a  tendency  to  extend,  espe- 
cially to  the  larynx.  The  subsequent  phenomena  are  those  of  stenosis  of 
the  larynx,  or  toxaemia,  with  or  without  superadded  uraemia  or  marked 
cardiac  weakness;  it  is  further  characterized  by  the  liability  to  paral- 
ysis as  a  sequel.  Diphtheria  is  spread  by  inhaling  the  expired  breath 
of  a  diphtheritic  patient,  or  breathing  air  which  has  been  contaminated 
by  the  clothing  of  the  patient  or  the  discharges  from  his  nose  and  throat. 
It  may  also  be  transmitted  directly,  as  when  a  fragment  of  membrane 
is  ejected  by  coughing  and  infects  the  mouth  or  eye  of  physician  or 
attendant.  Moreover,  it  is  contained  in  the  sewers  of  large  cities 
where  the  disease  is  endemic,  and  it  persists  in  damp  cellars  if  they 
have  once  been  infected.  Hence  sewer-gas  and  cellar-air  may  carry 
the  disease.  There  is  reason  also  for  believing  that  a  similar  disease 
affects  birds,  fowls,  and  cats  at  times,  and  from  them  may  be  trans- 
mitted to  man. 

The  specific  poison  is  the  Klebs-Loffler  bacillus  and  its  toxin. 

While  children  from  one  to  six  years  of  age  are  especially  liable  to 
it,  no  age  is  exempt — neither  the  newborn  babe  nor  the  very  aged. 

One  attack  does  not  protect  a  person  completely  against  a  subsequent 
attack. 

The  period  of  incubation  varies  from  a  few  days  to  two  weeks,  or 
perhaps  longer  in  exceptional  cases.  As  a  rule,  it  is  less  than  a  week. 
It  is  shorter  when  the  poison  is  virulent,  and  when  infection  has  been 
upon  abraded  surfaces. 

The  onset  in  mild  cases  is  deceptively  free  from  positive  symptoms. 
The  child  is  languid,  perhaps  slightly  chilly,  and  has  a  little  fever, 
with  thirst,  impaired  appetite,  and  discomfort  in  swallowing.  Unless 
the  nature  of  the  trouble  is  suspected  the  child  is  not  thought  ill 
enough  to  be  kept  indoors.  The  throat  is  slightly  inflamed,  especially 
about  the  tonsils.  The  child  may  protest  that  there  is  no  pain  on 
swallowing.  In  from  twelve  to  twenty-four  hours  from  the  onset, 
sometimes  later,  a  grayish  pellicle  will  be  found  upon  the  tonsils,  and 
the  cervical  glands  will  be  swollen. 

In  more  severe  cases  the  disease  begins  with  chill  or  chilliness,  fol- 
lowed by  a  rise  in  the  temperature  to  102°  to  104°,  sore-throat,  and 
sometimes  vomiting,  though  this  is  not  so  common  as  in  scarlatina. 
Convulsions  and  delirium  may  occur  if  the  fever  be  high  or  the  case 
malignant,  but  they  are  not  common.  Disgust  for  food  makes  it  diffi- 
cult to  nourish  the  patient.  Headache,  thirst,  and  aching  in  the  back 
and  limbs  may  be  complained  of.  Prostration  is  often  very  pro- 
nounced from  the  first. 

Objective  Symptoms.  As  pointed  out  by  Buzzard  and  McDonnell, 
the  patellar  tendon  reflexes  are  often  abolished  as  early  as  the  first  day. 
The  characteristic  false  membrane  appears  first  as  a  grayish  pellicle 
upon  one  or  both  tonsils,  and  spreads  thence  to  the  soft  palate  and  phar- 
ynx. The  membrane  soon  becomes  thicker  and  whitish  in  color;  when 
fully  developed  it  appears  like  white  or  grayish-white  parchment,  not 
lying  loosely  upon  the  surface,  but  imbedded  in  the  mucous  membrane, 


804  SPECIAL  DIAGNOSIS. 

the  inflamed  swollen  edges  of  which  rise  above  the  false  membrane, 
surrounding  it  "  as  the  crystal  of  a  watch  is  surrounded  by  the  rim  " 
(J.  Lewis  Smith1).  As  the  membrane  becomes  older  it  may  be  brown- 
ish, or  even  blackish  in  color,  if  tincture  of  iron  has  been  given.  If 
it  is  forcibly  torn  from  the  underlying  surface  hemorrhage  is  excited 
and  the  membrane  is  reformed.  As  the  membrane  loosens  sponta- 
neously there  is  often  marked  inflammatory  reaction  at  the  edges  of  the 
surrounding  mucous  membrane,  and  in  the  tonsils  there  may  be  decided 
sloughing  with  a  dark,  gangrenous  appearance. 

The  temperature  usually  falls  on  the  second  or  third  day,  but  this  does 
not  indicate  either  a  favorable  or  an  unfavorable  end.  A  temperature 
but  little  above  normal  is  not  uncommon  in  profound  toxaemia. 

Albumin  is  usually  present  early,  and  often  tube-casts  and  renal  epi- 
thelium also  can  be  found.  The  submaxillary  and  cervical  glands  are 
swollen  and  it  may  be  difficult  to  open  the  mouth  sufficiently  to  inspect 
the  throat. 

In  favorable  cases  the  membrane  ceases  to  extend  after  three  or  four 
days;  there  is  no  extension  to  the  larynx;  the  urine  is  free  from  albu- 
min, or  only  slightly  albuminous;  and  the  pulse  is  not  more  than 
100  to  120  and  of  good  force. 

In  unfavorable  oases  the  membrane  shows  a  tendency  to  extend, 
either  upward  into  the  nasal  fossae,  producing  a  thin,  irritating,  exco- 
riating discharge  from  the  nostrils,  and  rendering  mouth-breathing 
necessary;  or  it  may  extend  also  to  the  ears  through  the  Eustachian 
tube,  or  into  the  maxillary  sinus;  or  the  extension  may  be  down- 
ward into  the  larynx,  producing  laryngeal  stenosis.  This  is  announced 
by  hoarseness,  with  rapidly  increasing  difficulty  in  breathing.  Inspi- 
ration is  high-pitched,  noisy,  and  difficult;  the  patient  brings  all  the 
accessory  muscles  of  respiration  into  play,  the  alae  of  the  nose  play, 
the  ribs  are  sucked  in,  and  still  he  pants  for  breath.  Every  now  and 
then  a  paroxysm  of  coughing  produces  cyanosis. 

In  other  unfavorable  cases  the  throat-symptoms  are  not  dangerous, 
but  uraemia  develops.  The  urine  is  scanty,  contains  a  large  amount 
of  albumin,  considerable  blood,  and  numerous  blood,  epithelial,  and 
granular  casts.  There  are  oedema  of  the  feet  and  puffiness  of  the  eye- 
lids. There  is  apt  to  be  repeated  vomiting;  convulsions  followed  by 
coma  and  death  may  end  the  scene,  or  the  patient  may  slowly  emerge 
from  the  dark  valley. 

In  still  other  cases  the  diphtheritic  poison  affects  the  heart.  The 
pulse  becomes  feeble  and  very  frequent,  the  first  sound  very  faint ; 
acute  dilatation  of  the  right  heart  may  occur.  There  may  be  faintness 
and  a  tendency  to  cyanosis  on  the  slightest  provocation,  or  attacks  of 
sinking  and  faintne-s  may  come  without  warning;  in  still  other  cases 
sudden  exertion  induces  paralysis  of  the  heart,  and  death. 

In  some  malignant  cases  the  patient  is  overwhelmed  by  a  large  dose 
of  the  poison,  and  dies  in  from  one  to  three  days  in  collapse  from  acute 
toxaemia,  without  any  special  local  symptoms  to  account  for  it.  In 
others  the  false  membrane  extends  rapidly  over  the  fauces,  pharynx, 

1  Keating's  Cyclopaedia  of  Diseases  of  Children,  1889,  vol.  i.  606. 


THE  INFECTIO  US  DISEASES.  805 

and  nasal  cavities  to  the  larynx;  death  occurs  from  early  obstruction, 
or,  if  it  is  postponed,  there  is  extensive  sloughing,  with  death  from 
secondary  blood-poisoning  or  septic  pneumonia. 

In  exceptional  cases  the  membrane  is  primary  in  the  nares  or  larynx, 
or  develops  upon  some  abraded  surface,  as  a  burn,  or  in  the  vagina  of 
a  puerperal  woman.  It  may  also  attack  the  mucous  membrane  of  the 
eye  or  the  seat  of  a  recent  operation.  Diphtheria  also  occurs  as  a 
complication  of  other  diseases,  particularly  scarlet  fever. 

The  most  frequent  sequehe  are  anaemia,  albuminuria,  and  paralysis. 
The  latter  comes  on  in  from  one  to  two  weeks  after  convalescence  has 
set  in,  but  it  may  appear  much  earlier,  and  in  exceptional  cases  later. 
It  may  be  marked  simply  by  loss  of  the  knee-jerk,  which  has  been 
alluded  to  already  in  the  symptomatology,  or  involve  the  palatal  and 
pharyngeal  muscles,  causing  nasal  voice,  difficulty  in  swallowing,  and 
regurgitation  of  food  through  the  nose,  or  there  may  be  multiple 
peripheral  neuritis. 

The  Pseudo-diphtheritic  Bacillus  resembles  the  genuine  in 
all  respects,  except  that  it  is  not  pathogenic.  It  seems  to  be  an 
attenuated  form  of  the  former. 

Loffler's  or  the  Klebs-Loffler  Bacillus.  This  is  found 
in  diphtheritic  pseudo-membranes,  especially  in  the  deeper  portions. 
It  is  not  found  in  the  blood. 

Morphology.  A  bacillus  2  to  3//  long  by  0.5  to  0.8//  broad,  straight 
or  slightly  curved,  with  very  many  irregular  forms. 

Biological  Properties.  It  is  facultative  anaerobic,  non-motile,  and 
does  not  liquefy  gelatin.  It  multiplies  by  fission.  Stains  with 
Loffler's  blue.  Certain  points  are  stained  intensely,  almost  black. 
It  grows  in  nutrient  gelatin,  nutrient  agar,  or  bouillon,  but  best  of  all 
in  Loffler's  blood-serum  mixture  (see  page  160)  at  35°.  (Death-point, 
58°,  ten  minutes'  exposure.)  It  forms  large  round  elevated  colonies, 
grayish-white  in  color  and  moist.  There  is  no  visible  growth  on  potato. 
Milk  is  a  good  soil  (see  Plate  I.,  Fig.  4). 

On  inoculation  it  causes  a  diphtheritic  pseudo-membranous  inflam- 
mation. 

It  generates  a  very  poisonous  toxin. 

Diagnosis.  Diphtheria  is  distinguished  from  ordinary  pharyngitis 
by  the  presence  of  membrane.  From  follicular  tonsillitis  by  the  pro- 
jecting mouths  of  the  follicles  containing  a  creamy-white  exudate. 
Later  the  exudate  may  cover  the  entire  surface  of  each  tonsil  and  be 
difficult  to  distinguish  from  false  membrane.  The  points  of  distinction 
are  that  in  the  former  the  exudate  lies  upon  the  surface  and  can  be 
brushed  off  without  force  and  without  leaving  a  bleediug  surface; 
whereas  in  diphtheria  the  membrane  is  imbedded  in  the  mucous  mem- 
brane and  cannot  be  torn  from  it  without  force.  A  raised,  red  inflam- 
matory border  of  mucous  membrane  at  the  junction  of  the  patch  is 
strongly  suggestive  of  diphtheria.  In  tonsillitis  there  is  no  appearance 
of  membrane  upon  the  soft  palate  or  pharnyx.  Furthermore,  in  ton- 
sillitis the  onset  is  attended  with  more  fever  and  pain  in  swallowing 
than  is  true  in  simple  tonsillar  diphtheria.  The  existence  of  albumin- 
uria and  swelling  of  the  cervical  glands  indicates  diphtheria,  and  the 


806  SPECIAL  DIAGNOSIS. 

absence  of  knee-jerk  is  an  important  but  not  constant  diagnostic  sign 
of  diphtheria.  The  presence  of  the  Klebs-Loffler  bacilli  in  a  culture 
from  a  suspected  throat  is  proof  of  the  existence  of  diphtheria. 

Erysipelas. 

An  acute,  specific,  contagious,  and  infectious  disease,  characterized 
by  a  sudden  onset,  with  a  bright-red  eruption,  which  usually  begins 
on  the  face  near  the  nose  or  mouth,  and  spreads  over  the  entire  face 
and  scalp.  It  is  attended  with  burning  heat  of  the  skin  and  great 
disfigurement  from  swelling.  The  specific  cause  of  erysipelas  is  the 
streptococcus  erysipelatosus.  It  is  carried  to  a  slight  extent  by  the  air, 
and  still  more  in  the  discharges,  especially  those  of  the  nose.  Repeated 
attacks  occur  in  persons  with  chronic  naso-pharyngeal  catarrh,  carious 
teeth,  or  a  sinus.  It  is  apt  to  attack  persons  with  open  wounds  (sur- 
gical erysipelas),  and  puerperal  women,  producing  in  these  cases 
sloughing  and  septicgemia.  When  on  the  body  it  spreads  over  a 
greater  extent  than  when  primary  on  the  face,  hence  its  name,  "  the 
red  runner."  It  may  pass  from  the  heel  to  the  thigh,  and  over  the 
trunk,  lasting  for  weeks.  One  attack  does  not  protect  against  another; 
on  the  contrary,  if  there  is  any  focus  in  which  the  streptococci  linger, 
one  attack  actually  predisposes  to  another. 

The  period  of  incubation  is  usually  from  three  days  to  a  week.  On 
close  inquiry  a  history  of  sore-throat  and  some  enlargement  of  the 
cervical  lymphatics  is  usually  found  to  precede  an  attack  of  facial  ery- 
sipelas. The  invasion  is  sudden  and  is  marked  by  chill.  The  tem- 
perature rises  to  104°  or  105°,  and  in  the  next  two  or  three  days  may 
rise  still  higher.  Coincidently  with  the  rise  in  temperature  the  portion 
of  the  skin  to  be  affected  burns,  tingles,  is  tender  to  the  touch,  and 
may  be  seen  to  be  reddened.  The  redness  increases  in  intensity  and 
extent,  while  the  skin  is  swollen  and  slightly  oedematous.  The  part  of 
the  face  to  be  affected  is  usually  the  cheek  in  close  proximity  to  the 
nose,  less  frequently  near  the  mouth  and  ear.  Vesicles  and  blebs  often 
form  when  the  inflammation  is  very  intense.  The  redness  disappears 
upon  pressure,  but  quickly  returns;  sometimes  it  has  a  dusky,  purplish 
hue.  A  marked  characteristic  of  the  disease  is  its  tendency  to  spread. 
In  ordinary  cases  it  involves  one  cheek,  eyelid,  and  ear,  and  travels 
across  the  bridge  of  the  nose  to  the  other  side.  The  inflammation  is 
most  intense  when  it  is  spreading;  the  advancing  margin  is  raised, 
tense,  and  brawny;  the  line  is  thus  sharply  drawn  between  healthy 
and  inflamed  tissue.  The  loose  tissue  about  the  eyes  swells  enormously, 
both  eyes  are  closed,  the  entire  face  swollen,  red,  and  disfigured  with 
vesicles  and  blebs  here  and  there.  Curiously  the  chin  escapes.  The 
redness  and  swelling  begin  to  subside  in  the  part  first  attacked,  before 
the  process  has  reached  its  height  on  the  opposite  side.  As  a  rule,  facial 
erysipelas  does  not  extend  beyond  the  face,  the  scalp  and  neck  being 
spared.  The  scalp,  however,  is  more  frequently  affected  than  the  neck; 
occasionally  erysipelas  leads  to  extensive  cellulitis  of  the  scalp,  with  the 
production  of  a  septic  constitutional  condition  and  much  local  sloughing. 
The  submaxillary  glands  are  more  or  less  enlarged,  sometimes  so  much 


THE  INFECTIOUS  DISEASES.  807 

so  as  to  prevent  the  taking  of  solid  food.  While  the  erysipelas  is  ex- 
tending the  fever  continues  and  is  sometimes  alarmingly  high.  The 
pulse  is  frequent  and  soft.  Nocturnal  delirium  is  not  uncommon  in 
severe  cases,  and  sometimes  nausea  and  vomiting  are  frequent.  The 
bowels  are  usually  constipated.  The  urine  is  high-colored,  frequently 
contains  a  small  amount  of  albumin,  and  actual  nephritis  sometimes 
occurs. 

In  favorable  cases  of  facial  erysipelas  the  process  is  at  an  end  in  a 
week  or  less.  It  may  be  prolonged  to  two  weeks,  subsiding  by  crisis 
or  lysis,  and  convalescence  is  usually  rapid.  The  vesicles  or  bullae 
dry  up  into  yellowish  crusts  and  the  epiderm  is  shed  in  large  or  small 
pieces  according  to  the  intensity  of  the  process. 

Pneumonia  and  nephritis  are  the  most  frequent  complications.  Men- 
ingitis, pericarditis,  and  endocarditis  also  occur.  Erysipelas  may  extend 
inward  and  involve  the  fauces,  pharynx,  and  larynx,  producing  oedema 
and  death  from  suffocation. 

Sequelce.  If  the  scalp  has  been  involved,  the  hair  falls  out.  The 
cervical  adenitis  may  result  in  abscess ;  chronic  nephritis  may  result. 
Otitis  media  occurs  occasionally,  and  so  do  keratitis  and  abscess  of  the 
eyelids. 

On  the  other  hand,  erysipelas  is  credited  with  causing  the  disappear- 
ance of  lupus,  chronic  eczema,  and  sarcomata. 

Diagnosis.  Herpes  zoster  of  the  face  and  forehead  is  distinguished 
from  erysipelas  by  the  fact  that  vesicles  appear  first,  followed  by  ery- 
thematous redness,  and  that  they  are  limited  by  the  median  line,  and  are 
preceded  and  accompanied  by  sharp  neuralgic  pain,  whereas  erysipelas 
affects  both  sides  of  the  face,  and  vesicles  appear  at  the  height  of  the 
disease;  the  pain  is  much  less  in  erysipelas. 

From  dermatitis  of  various  kinds  it  is  distinguished  mainly  by  the 
sharper  febrile  reaction,  the  raised  border  of  the  eruption,  which  begins 
on  one  side  and  spreads  to  the  other.  Erysipelas  is  rarely  equally 
intense  upon  the  two  sides.  Dermatitis  frequently  is.  The  latter 
often  exhibits  a  rough  surface,  whereas,  until  vesicles  appear,  erysipelas 
is  smooth  and  shiny. 

Chronic  erythematous  eczema  occurs  in  the  middle-aged  and  old  per- 
sons, is  afebrile,  accompanied  by  little  swelling  but  a  great  deal  of 
itching,  and  runs  a  slow  course. 

Cholera. 

An  acute,  specific,  infectious  disease,  endemic  in  parts  of  India,  but 
occurring  in  epidemics  elsewhere,  characterized  by  the  outpouring  into 
the  stomach  and  bowels  of  large  quantities  of  a  serous  fluid  resembling 
rice-water,  which  fluid  is  usually  vomited  and  discharged  from  the 
intestines.  It  is  further  characterized  by  an  algid  state  of  collapse  and 
by  painful  muscular  cramps. 

The  specific  poison  of  cholera  is  believed  to  be  the  comma-bacillus 
of  Koch,  and  its  ptomaine. 

The  native  habitat  of  cholera  is  India,  particularly  the  neighborhood 
of  Calcutta;  here  it  is  endemic  and  thence  it  is  liable  to  spread  in  sue- 


SPECIAL  DIAGNOSIS. 

cessive  epidemic  waves  along  the  lines  of  travel  by  sea  and  land,  over 
the  whole  world.  It  is  scarcely,  if  at  all,  contagious;  the  poison  is 
contained  in  the  vomit  and  dejections,  which  contaminate  the  drink- 
ing-water, food,  and  clothing.  The  cholera-bacillus  preserves  its 
vitality  for  long  periods  of  time  in  water,  especially  if  the  water  is 
slightly  alkaline  and  contains  vegetable  matter,  and  in  moist  clothing, 
as  rags. 

The  period  of  incubation  is  probably  short  in  the  majority  of  cases, 
lasting  only  a  few  days.  Occasionally  it  is  two  weeks.  There  are 
usually  no  definite  symptoms  during  this  time,  but  there  may  be  a 
sense  of  weakness,  with  loss  of  appetite  and  dyspeptic  symptoms. 

First  Stage.  The  first  stage,  that  of  premonitory  diarrhoea,  is  better 
regarded  as  the  beginning  of  true  cholera.  It  is  characterized  by  pro- 
fuse watery  stools  of  a  yellow  or  light-yellow  color,  and  alkaline  in 
reaction.  They  are  accompanied  by  a  rumbling  noise  in  the  bowels, 
but  are  passed  without  pain.  From  six  to  a  dozen  of  these  passages 
occur  in  twenty-four  hours.  The  patient  feels  faint  and  exhausted 
after  them,  and  may  suffer  with  nausea,  but  vomiting  is  not  usual. 
In  severe  cases  there  may  be  cramps  in  the  calves  of  the  legs.  The 
voice  is  faint  and  husky,  thirst  intense,  the  tongue  white  and  moist. 
The  temperature  is  normal  or  slightly  depressed. 

This  stage  may  last  from  two  days  to  a  week,  depending  upon  treat- 
ment. In  some  cases  it  is  wholly  absent,  and  the  patient  is  ushered 
abruptly  into  the 

Second  Stage.  This  usually  comes  on  during  the  night.  The  patient 
is  seized  with  vomiting  which  is  at  first  bilious,  but  the  fluids  rapidly 
lose  all  color  and  become  like  rice-water.  The  stools  likewise  resemble 
water  in  which  meal  has  been  stirred,  or  in  which  rice  has  been  soaked 
— a  semi-transparent  fluid  with  particles  of  epithelium  resembling  rice 
floating  in  it.  This  fluid  seems  to  well  up  and  regurgitate  rather  than 
to  be  vomited  from  the  stomach,  and  to  gush  in  quantities  of  a  quart 
or  two  from  the  anus.  Sometimes  vomiting  and  diarrhoea  occur  at 
once.  The  patient  has  unquenchable  thirst,  and  is  tortured  with  pain- 
ful cramps  of  the  toes,  legs,  belly,  and  diaphragm.  As  the  discharges 
continue  the  patient  becomes  more  and  more  exhausted ;  the  nose  is 
pinched  and  twisted,  the  eyes  sunken,  the  lips  bluish,  and  the  whole 
body  may  shrink  beyond  recognizable  proportions. 

The  skin  is  cold  and  moist,  the  breath  icy,  and  the  temperature 
under  the  tongue  is  sometimes  as  low  as  78°  to  80°  F.  In  the  vagina 
and  rectum  it  may  be  normal  or  slightly  above  normal.  The  patient, 
however,  often  has  a  sensation  of  heat.  The  urine  is  very  scanty, 
containing  albumin  and  sugar,  or  it  may  be  suppressed.  The  pulse  is 
very  small  and  feeble,  100  to  120.  The  mind  is  clear,  but  the  patient 
is  listless,  answering  questions  in  an  extremely  faint  voice  and  with 
manifest  effort. 

Third  Stage.  From  this  collapsed  and  aigid  condition  the  patient 
may  slowly  emerge,  the  skin  becoming  less  cold,  the  cramps  less  severe. 
A  return  of  the  secretion  of  uriue  is  a  hopeful  sign.  The  reaction, 
however,  may  simply  introduce  a  low  typhoid  condition,  with  fever, 
dry  brown  tongue,  subsultus,  low  muttering  delirium,  and  coma. 


THE  INFECTIOUS  DISEASES.  809 

In  some  cases  serum  is  poured  out  into  the  stomach  and  iutestines  and 
is  retained  there.  The  patient  may  be  seized  while  walking  with  dizzi- 
ness, faintness,  extreme  prostration,  and  early  collapse. 

In  other  cases  the  patient  is  smitten  down  with  profuse  vomiting  and 
purging,  dying  algid  and  collapsed  in  a  few  hours,  no  reaction  appearing. 

In  favorable  cases  the  vomiting  ceases,  the  stools  become  less  fre- 
quent and  are  tinged  with  bile  and  have  a  faecal  odor.  The  urine 
increases  in  volume,  while  the  albumin  diminishes.  Convalescence  is 
very  protracted.  Anaemia,  great  debility,  feeble  digestion,  and  some- 
times obstinate  diarrhoea  delay  complete  recovery.  Relapses  are  fre- 
quent. 

In  other  cases  reaction  brings  improvement  in  the  gastro-intestinal 
symptoms,  but  uraemia  develops,  death  following  in  convulsions  or 
coma. 

The  most  frequent  complications  and  sequela?  are  eruptions,  chiefly 
erythematous,  ulcerations  and  bedsores,  parotitis,  and  a  painful  tetanic 
spasm  of  the  flexor  muscles  of  the  hands,  forearms,  legs,  and  feet, 
occurring  between  the  tenth  and  fifteenth  days  of  convalescence  (Stills). 

Diagnosis.  The  chief  points  in  the  diagnosis  from  other  affections 
are  the  knowledge  of  exposure  to  cholera;  the  character  of  the  vomit 
and  dejecta,  which  contain  the  comma-bacillus  (for  its  detection  see 
under  Bacteriology);  the  cyanosis;  the  rapid  development  of  collapse, 
with  cold  skin,  icy  breath,  torturing  cramps,  and  greatly  shrunken 
visage  and  body. 

Cholera  morbus  differs  in  that  the  stools  remain  turbid  with .  bile  or 
faecal  matter,  or  contain  blood;  they  never  present  the  rice-water 
appearance.  Moreover,  the  passages  are  frequently  preceded  by  col- 
icky pains.  Cyanosis  and  collapse  are  extremely  rare.  The  stools  do 
not  contain  the  cholera-bacillus. 

Other  forms  of  acute  toxic  gastro-enteritis,  whether  from  ptomaine- 
poisoning  or  from  corrosive  poison,  are  to  be  distinguished  by  the 
history,  the  difference  in  the  character  of  the  stools,  and  the  compara- 
tive absence  of  painful  cramps  in  the  legs,  of  cyanosis,  and  of  collapse. 

Bacteriological  Diagnosis  of  Cholera.  Koch  remarks  :'  "As 
cholera  resembles  in  clinical  symptoms  cholera  nostras,  infantile  chol- 
era, certain  forms  of  peritonitis,  certain  organic  poisons,  and  poisoning 
by  arsenic,  it  is  important  to  attain  some  means  of  making  a  definite 
dagnosis. ' ' 

The  Microscopical  Examination.  Coyer-glass  preparations  of  the 
dejections  of  the  patient  or  of  a  flake  of  mucus  from  some  fluid  of  the 
body  are  made.  The  preparation  is  stained  by  Ziehl's  red  (fuchsin). 
In  addition  to  the  cholera-bacilli,  the  bacillus  coli  communis  and  other 
intestinal  bacteria  are  found.  The  cholera-bacilli  lie  in  groups  in  the 
thread-like  strands  of  mucus.  They  form  in  heaps,  the  bacilli  lying 
in  the  same  direction.  Koch  holds  that  this  mode  of  grouping  is 
characteristic  and  diagnostic.  He  further  holds  that  if  bacilli  coli  are 
in  close  proximity  to  numerous  scattered  bacteria  resembling  the  chol- 
era bacilli,  the  case  is  one  of  Asiatic  cholera. 

1  Zeitschrift  fur  Hygiene  uud  Infektiouskranheiten,  1S93,  vol.  xiv.,  No.  2. 


810  SPECIAL  DIAGNOSIS. 

Peptone-cultivation.  A  small  quantity  of  the  dejection  of  some  flake 
of  mucus  is  inserted  with  a  platinum  loop  into  a  sterilized  1  per  cent, 
peptone  solution.  The  solution  is  maintained  at  37°  C.  The  cholera 
bacteria  are  aerobic,  and  develop  on  the  surface  of  the  peptone,  while 
the  faecal  bacteria  remain  in  the  deeper  layers.  As  soon  as  the  peptone 
is  cloudy  a  drop  from  the  surface  is  examined  microscopically.  Within 
six  the  hours  surface  is  overwhelmed  with  a  pure  culture  of  cholera- 
bacilli.  Later  they  are  mixed  with  bacteria  coli.  The  examination 
should  be  made  from  six  to  twelve  hours  after  the  peptone  solution  is 
inoculated.  The  peptone  solution  should  be  strongly  alkaline,  and 
a  1  per  cent,  solution  of  common  salt  should  be  added.  Care  must 
be  taken  to  see  that  the  solution  contains  sufficient  soda.  In  plate 
cultivations  the  cholera-bacilli  are  overwhelmed  by  the  faecal  bacteria. 

Gelatin-plate  Cultivation.  Three  dilations  are  prepared  and  poured 
into  double-bottomed  vessels.  The  vessel  must  be  submitted  to  a 
temperature  which  is  warm,  but  does  not  liquefy  the  gelatin,  as  about 
22°  C.  The  colonies  are  seen  in  from  fifteen  to  twenty  hours.  If 
the  gelatin  becomes  liquid,  the  cholera  colonies  resemble  Finkler's 
bacteria. 

Agar-plate  Cultivation.  The  growth  is  not  so  characteristic  as  it  is 
in  gelatin.  The  cholera-bacilli  form  large  colonies  of  light  gray-brown 
transparent  appearance.  Colonies  of  other  bacteria  are  less  transparent. 
The  colonies  can  be  obtained  in  from  eight  to  ten  hours  after  exposure 
to  a  temperature  of  37°  C.  Microscopical  examination  of  the  colonies 
must  be  made. 

Cholera-red  Reaction.  Cholera-cultivations  contain  indol  and  nitrous 
acid,  and  produce  a  red  color  if  sulphuric  acid  is  added.  This  color 
is  produced  by  other  bacteria  also,  but  by  none  other  of  the  bacteria 
that  are  curved.  Care  must  be  taken  to  make  the  cultivations  with 
suitable  peptone,  and  to  have  the  sulphuric  acid  free  from  nitrous  acid. 

Experiments  on  Animals.  The  agar-cultivations  are  employed. 
They  must  be  introduced  into  the  abdominal  cavity  of  the  guinea-pig. 
The  injection  must  not  be  made  into  the  intestine,  a  matter  which 
requires  considerable  practice.  Xo  other  spirillum  or  curved  bacillus 
produces  the  symptoms. 

Dengue. 

An  acute  contagious  disease,  occurring  in  epidemics  and  characterized 
by  severe  pains  in  the  head,  back,  and  joints,  various  skin  eruptions, 
a  prolonged  convalescence,  and  a  very  low  rate  of  mortality. 

The  disease  occurs  in  epidemics  in  tropical  and  subtropical  countries, 
and  rarely  in  cooler  climates.  It  derives  its  name  dengue  (dandv), 
from  the  stiff  and  unnatural  gait  assumed  by  convalescent  patients. 
In  the  southern  parts  of  the  United  States  an  expressive  name  given 
to  the  disease  is  "  breakbone  fever." 

The  specific  cause  of  the  disease  is  believed  by  Dr.  McLoughlin  to 
be  a  micrococcus  which  he  isolated.  The  period  of  incubation  is  short, 
varying,  however,  from  a  few  minutes  to  several  days,  or  even  a  week. 
Invasion  is  very  sudden  and  is  rarely  preceded  by  any  prodromata. 
It  is  marked  by  chilliness  or  a  chill,  and  very  severe  pains  in  the  head, 


THE  INFECTIO  US  DISEASES.  811 

back,  and  limbs.  In  children  the  onset  may  be  by  convulsions,  which 
are  sometimes  followed  by  stupor  and  vomiting.  The  pains  are  some- 
times excruciating  and  are  accompanied  by  tenderness  of  the  muscles; 
there  is  extreme  debility.  The  temperature  rises  to  102°  or  103°,  but 
rarely  is  much  higher. 

The  pulse  is  frequent — 110,  120,  or  more.  In  from  one  to  three  or 
five  days  the  temperature  falls  to  or  below  normal  (the  remission), 
accompanied  by  sweating  or  diarrhoea,  and  fluctuates  about  this  level 
for  several  days,  when  a  second  and  moderate  rise  in  temperature,  which 
is  of  short  duration,  occurs.  During  the  first  rise  in  temperature  there 
is  a  transient,  generally  scarlatiniform  rash,  which  is  not  followed  by 
desquamation.  The  urine  is  febrile,  but  not  albuminous.  During  the 
remission  eruptions — scarlatiniform,  herpetic,  urticarial,  or  like  miliaria 
— begin  to  appear,  accompanied  by  the  secondary  rise  in  temperature. 
The  eruptions  may  be  in  successive  crops  and  are  followed  by  desqua- 
mation. Convalescence  is  now  established,  but  may  be  interrupted  by 
relapses.  Strength  is  regained  very  slowly.  The  most  frequent  com- 
plications are  disorders  of  the  nervous  system,  but  bronchitis  and  diar- 
rhoea occasionally  occur. 

Malarial  Fevers. 

A  group  of  fevers  associated  with  the  protozoan  organism  of  Lav- 
eran,  and  characterized  by  periodic  paroxysms  of  chill,  fever,  and  sweat. 
They  are  not  contagious,  but  can  be  transmitted  by  inoculation. 

Malarial  fevers,  while  most  prevalent  in  tropical  and  subtropical 
regions,  are  found  also  throughout  the  temperate  zone,  especially  in 
autumn  and  spring.  In  Europe  their  favorite  habitat  is  Italy,  and  in 
the  United  States  the  southern  and  southwestern  States.  Conditions 
that  especially  favor  their  development  are  marshes  and  swamps,  fed 
partly  by  sea- water;  low  ground  along  streams  of  slow  current;  and 
freshly  upturned  soil. 

The  poison  is  carried  in  the  air,  hence  winds  blowing  from  marshes 
or  other  infected  districts  are  especially  dangerous. 

The  specific  poison  in  malarial  fevers  is  no  doubt  organic.  The  pro- 
tozoan organism  described  by  Laveran  exhibits  several  different  forms, 
which  he  regards  as  stages  in  the  development  of  one  organism,  but 
which  may  be  different  species.  Golgi  maintains  that  there  are  several 
distinct  varieties  of  parasites  whose  periodicity  in  development  and 
sporulation  corresponds  with  the  different  types  of  fevers. 

Intermittent  Fever.  This  is  a  type  of  malarial  fever  in  which 
the  temperature  remains  normal  between  the  paroxysms. 

A  malarial  paroxysm  is  characterized  by  (1)  chill,  (2)  fever,  and  (3) 
sweating,  occurring  in  the  order  named  and  in  immediate  succession. 
The  time  between  the  beginning  of  one  paroxysm  and  the  beginning  of 
the  next  is  called  the  "  interval,"  that  between  the  conclusion  of  a 
paroxysm  and  the  beginning  of  the  next  the  "  intermission."  The 
interval  varies  in  different  forms  of  intermittent  fever  :  in  the  quotidian 
there  is  a  paroxysm  every  day,  with  an  interval  of  twenty-four  hours: 
in  tertian  there  is  a  paroxysm  on  alternate  days,  with  an  interval  of 


812  SPECIAL  DIAGNOSIS. 

forty-eight  hours;  in  the  quartan  there  is  a  paroxysm  every  third  day, 
with  an  interval  of  seventy-two  hours.  In  double  quotidian  there  are 
two  paroxysms  in  the  twenty-four  hours,  but  not  of  the  same  intensity. 

In  the  double  tertian  there  is  a  paroxysm  every  day,  the  first  and 
third  and  second  and  fourth  corresponding  as  to  hour  and  intensity. 
That  is  to  say,  if  there  be  a  paroxysm  at  10  a.m.  Monday,  there  will 
be  another  severe  paroxysm  at  10  a.m.  Wednesday,  while  on  Tuesday 
and  Thursday  there  will  be  milder  paroxysms,  but  at  another  hour 
than  10  a.m. 

In  the  double  quartan  severe  and  mild  paroxysms  succeed  each 
other  every  other  day,  but  each  third  day  is  free  from  any  paroxysm. 

While  the  rule  is  for  malarial  fevers  to  occur  periodically  at  the  same 
hour,  the  second  paroxysm  may  occur  an  hour  or  two  earlier  (antici- 
pation) if  the  disease  is  growing  worse,  or  an  hour  or  two  later  (post- 
ponement) if  it  is  growing  better. 

Quotidian  intermittents  are  slightly  more  common  than  tertian,  while 
the  quartan  variety  is  rare. 

The  incubation--per'iod  probably  varies  widely,  depending  upon  the 
intensity  of  the  poison.  As  a  rule,  repeated  exposure  is  necessary  to 
develop  the  disease  in  temperate  climates.  During  this  period  the 
patient  may  suffer  with  headache,  drowsiness,  pains  and  aching  in  the 
limbs  and  back,  constipation,  a  coated  tongue,  and  thirst. 

The  onset  of  a  typical  malarial  paroxysm  is  marked  by  chilly  sensa- 
tions, especially  along  the  spine,  accompanied  by  yawning  and  the 
development  of  "  goose-flesh."  Then  a  decided  chill  sets  in,  the  patient 
shaking  violently.  The  face  is  pale  and  pinched,  the  lips  blue,  the 
nose  pointed;  as  the  chill  becomes  worse  the  teeth  chatter,  the  whole 
body  feels  cold,  the  skin  feeling  rough,  dry,  cold,  and  harsh.  The 
finger-nails  and  toe-nails  are  blue,  the  skin  being  wrinkled  upon  the 
palmar  and  plantar  surfaces.  The  superficial  bloodvessels  are  so  con- 
tracted that  a  drop  of  blood  is  obtained  with  difficulty.  The  voice  is 
thin  and  weak,  almost  inaudible. 

The  volume  of  blood  driven  from  the  surface  leads  to  congestion  of 
the  viscera,  particularly  the  spleen,  liver,  and  stomach.  Nausea  and 
vomiting  are  not  uncommon.  The  spleen  is  perceptibly  enlarged,  and 
frequently  the  liver  also. 

Although  the  surface-temperature  is  depressed,  the  internal  tempera- 
ture is  rising,  and  may  be  two  or  three  degrees  above  normal.  By  de- 
grees the  severity  of  the  chill  abates  and  the  patient  asks  to  have  the  extra 
bedclothing  removed.  Reaction  has  set  in.  The  surface-bloodvessels 
dilate  and  the  skin  becomes  flushed.  The  temperature  continues  to 
rise,  often  reaching  103°  to  106°,  pulse  and  respiration  increasing  cor- 
respondingly in  frequency.  The  patient  complains  of  a  throbbing, 
dizzy  headache,  and  vomiting  may  recur.  The  bowels  remain  con- 
stipated. The  temperature  now  begins-  to  fall,  and  the  sweating-stage 
succeeds.  Perspiration  appears  first  upon  the  forehead,  face,  and  neck, 
and  gradually  extends  over  the  rest  of  the  body.  The  perspiration 
becomes  more  and  more  profuse,  until  the  whole  body  is  drenched 
with  it.  All  the  subjective  symptoms  vanish  with  wonderful  rapidity, 
and  the  patient,  with  the  exception  of  exhaustion,  seems  to  be  restored 


PLATE    XI. 


FIG.  i. 


r> 


/     *. 


Anthrax-bacilli  from  Rabbit's  Spleen. 

(Oc.  4,  ob.  1/12  immersion.)    Drawn  by  J.  D.  Z.  Chase. 


FIG.   2. 


<*&§!*. 


U       Jg&W 


Protozoa  of  Malaria,  intracellular  and  crescentic  forms. 

lOc  1,  oh.  1 ',._,  immersion. J     Drawn  by  ,T.  D.  Z.  Chase. 


THE  INFECTIO  US  DISEASES. 


813 


to  complete  health.  The  hot  stage  lasts  from  one  to  two  hours,  the 
cold  stage  from  three  to  eight  hours,  and  the  sweating-stage  from  two 
to  six  hours. 

In  the  interval  between  paroxysms  the  patient  is  free  from  fever,  but 
is  angemic,  weak,  and  has  impaired  appetite,  and  constipation.  Dur- 
ing the  entire  paroxysm  the  mind  remains  clear. 

The  chief  objective  symptom  apart  from  the  phenomena  of  chill,  fever, 
and  sweat  already  described,  is  the  occurrence  of  plasmodia  in  the 
blood  (see  under  Blood,  and  Plate  XI.,  Fig.  2;  and  Fig.  159). 


Fig.  158. 


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Intermittent  fever.    Temperature  every  six  hours.    Morning  and  evening  temperature 
and  highest  at  chill. 


Irregular  Form.  Irregular  forms  of  intermittent  fever  are  more 
common  in  Philadelphia  than  the  typical  form  just  described. 

In  the  mild  form  the  patient  complains  of  great  lassitude,  irritability 
of  temper,  and  drowsiness  during  the  day,  but  at  night  tosses  upon 
his  bed  and  gets  up  in  the  morning  more  tired  than  when  he  went  to 
bed.  The  back  and  limbs  ache,  and  the  latter  feel  as  though  they 
would  give  way  under  him.  There  is  severe,  throbbing  headache,  with 
some  dizziness  and  faintness.  The  bowels  are  constipated;  the  tongue 
heavily  coated  with  yellow  fur.  The  temperature  is  moderately  ele- 
vated and  the  patient  has  great  thirst.  Nausea  and  vomiting  are 
absent,  though  there  is  little  desire  for  food.  There  may  be  a  burning 
feeling  referred  to  the  splenic  region.  The  patient  is  worse  on  alternate 
days,  and  the  attacks  may  be  preceded  by  slight  creeping  chills.  On 
inquiry  the  patient  will  be  found  to  live  in  a  low-lying  district  near  one 


814  SPECIAL  DIAGNOSIS. 

of  the  rivers,  or  in  a  damp  house  over  an  unclean,  moist  cellar,  or 
adjoining  a  place  where  fresh  soil  has  been  upturned. 

In  the  form  known  as  "dumb  ague"  there  is  periodically  great 
depression,  with  aching  in  the  head  and  limbs,  a  sensation  of  coldness 
rather  than  chilliness,  but  no  marked  fever  and  sweating.  Nausea 
and  vomiting  may,  however,  be  present.  Da  Costa  says  he  has  seen 
it  manifest  itself  by  excruciating  pain  over  the  kidney,  and  almost 
entire  suppression  of  urine.  There  may  also  be  severe  paroxysms  of 
gastralgia.     It  is  more  common  in  old  residents  of  malarious  districts. 

In  masked  malarial  fever  the  poison  manifests  itself  in  an  attack  of 
neuralgia,  especially  of  the  supraorbital  nerve  and  gastric  nerves. 
Malaria  may  also  be  latent  until  some  impairment  of  the  resistiug- power 
brings  it  to  light.  Hence  it  appears  as  a  complication  of  pneumonia 
and  dysentery,  and  typhoid  fever  (constituting  typho-malarial  fever), 
especially  in  the  southern  and  southwestern  portions  of  the  United 
States.  Moreover,  women  who  have  previously  had  intermittent  fever 
may  suffer  a  recurrence  after  confinement. 

Diagnosis.  The  essential  points  in  the  diagnosis  of  intermittent 
fever  are  the  periodical  recurrence  of  paroxysms  of  chill,  fever,  and 
sweating,  or  of  attacks  of  dumb  ague,  or  of  paroxysms  of  neuralgia, 
without  organic  lesion,  associated  with  the  presence  in  the  blood  of 
pigment  and  plasmodia,  and  with  enlargement  of  the  spleen  and  possi- 
bly of  the  liver.  A  typical  malarial  intermittent  fever  is  not  likely  to 
be  mistaken  for  anything  else  (see  Fever,  pages  104,  105).  It  needs, 
however,  to  be  distinguished  from  septicemic  fever,  due  to  absorption 
into  the  blood  of  pus  and  the  toxins  produced  by  bacteriological  growth. 
Such  fever  occurs  in  tuberculosis,  especially  in  the  stage  when  cavities 
form  and  pus  collects;  in  the  puerperal  state,  in  empyema,  subphrenic 
abscess,  abscess  of  the  liver,  or  it  may  occur  in  any  form  of  suppuration. 
Here  also,  then,  are  recurring  chills,  with  fever  and  sweating,  but  the 
attacks  are  not  regularly  periodical  and  intermittent;  sometimes  the 
fever  is  intermittent  and  sometimes  remittent,  the  chills  recur  at  irreg- 
ular intervals,  and  are  not  so  violent  as  in  the  malarial  attack.  The 
essential  difference,  however,  lies  in  the  fact  that  a  local  cause  can  be 
found  to  explain  them,  tuberculosis  either  of  the  lung  or  of  some  other 
viscus,  or  a  collection  of  pus  in  an  organ  or  cavity,  or  a  fcetid  dis- 
charge from  the  womb,  with  local  tenderness  or  peritonitis;  moreover, 
the  patient  loses  flesh  more  or  less  rapidly,  his  blood  is  free  from 
malarial  germs  and  pigment,  and  quinine  does  not  control  the  fever. 
(Plate  XL,  Fig.  2.) 

From  the  intermittent  fever  of  hepatic  origin  (described  elsewhere 
by  the  author)  the  diagnosis  is  more  difficult,  in  that  physical  signs  of 
any  local  trouble  may  be  wanting.  But  the  fever  is  not  regularly 
intermittent,  is  not  controlled  by  the  quinine,  but  may  be  by  measures 
directed  to  the  origin  of  the  trouble,  and  jaundice  may  be  present. 

Urethral  fever,  occurring  as  the  result  of  operations  upon  the  urethra, 
or  simply  from  the  passage  of  a  catheter  or  bougie,  may  be  mistaken 
for  malarial  fever;  but  the  paroxysm  is  usually  single,  and  the  history 
of  the  operation  and  the  absence  of  plasmodia  from  the  blood  clear  up 
the  diagnosis. 


THE  INFECTIO  US  DISEASES. 

Fig.  159. 


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The  first  twelve  figures  show  the  malarial  Plasmodium.  It  is  a  pale  amoeboid  body  inside  the 
red  corpuscle.  It  increases  in  size  at  the  expense  of  the  corpuscles.  In  the  last  four  of  the  twelve 
it  is  enlarged  and  contains  pigment-granules  derived  from  the  haemoglobin.  The  figures  of  the 
fourth  row  show  progressive  stages  in  the  process  of  cleavage  of  the  Plasmodium  and  shitting  ot 
the  pigment-granules.  In  the  fifth  row  the  process  of  cleavage  is  seen  to  be  completed,  and  final 
isolation  of  the  spores  has  taken  place.  The  dark  granules  are  pigment-granules.  The  last  row 
shows  oval  parasites— Laveran's  corpuscles  observed  in  atypical  cases  of  malaria.  (From  Golgi, 
"  Studien  fiber  Malaria,"  Fortschritte  der  Medicin,  Bd.  iv.,  Tafel  m.) 


816 


SPECIAL  DIAGNOSIS. 


Syphilitic  fever  is  distinguished  by  a  tendency  for  the  chill,  fever,  and 
sweating  to  be  nocturnal  in  recurrence,  and  by  evidence  of  syphilitic 
infection  coupled  with  absence  of  malarial  germs  from  the  blood. 


Fig.  160. 


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A  form  of  intermittent  fever  from  syphilis.    J.  D.,  aged  twenty-six  years.    Secondary  period. 
Mercury  and  iodide  of  potash  relieved  it.     Observe  that  the  pulse-frequency  is  not  increased. 

Remittent  Malarial  Fever.  A  type  of  malarial  fever  char- 
acterized by  a  remission  instead  of  an  intermission  in  the  febrile  parox- 
ysms. It  is  due  either  to  a  greater  intensity  of  the  malarial  poison  or 
to  a  different  species  of  organism.  It  is  much  more  rare  in,  temperate 
climates  than  either  quotidian  or  tertian  intermittent,  and  is  attended 
with  more  gastric  disturbance  and  a  much  larger  mortality  (twelve 
times  greater,  according  to  the  statistics  of  the  Civil  War). 

The  onset  is  more  abrupt  than  in  intermittent  fever.  Prodromata 
are  not  so  common,  but  wheu  they  occur  they  are  of  the  same  char- 
acter. The  chill  is  not  usually  so  violent,  nor  the  cold  stage  so  long 
as  in  intermittent  fever;  on  the  other  hand,  nausea  and  vomiting  are 
common,  and  in  some  cases  there  are  bilious  vomiting  and  diarrhoea, 
tenderness  over  the  stomach  and  spleen,  and  sometimes  jaundice.  The 
temperature  rises  rapidly  to  103°  to  106°  and  remains  high  for  a  longer 
time  than  in  intermittent  fever,  the  hot  stage  lasting  in  severe  cases 
from  six  to  eighteen  or  twenty  hours. 

During  this  time  the  patient  suffers  from  headache,  pains  in  the 
back  and  limbs,  great  thirst,  and  gastric  irritability.  A  remission 
now  succeeds.  The  temperature  falls  two  or  three  degrees,  but  not 
to  normal;  free  sweating  occurs,  the  nausea  and  vomiting  cease,  and 
the  patient  becomes  much  more  comfortable.  He  may  fall  asleep  from 
exhaustion,  but  if  awake  is  conscious  of  weakness,  aching  in  the  limbs, 
and  perhaps  nausea.  In  the  course  of  some  hours  the  temperature 
again  rises,  often  to  a  higher  point  than  before,  but  frequently  with- 


THE  INFECTIOUS  DISEASES.  .  817 

out  antecedent  chill.  The  same  subjective  symptoms  are  repeated, 
and  another  remission  follows.  Daily  paioxysms  usually  occur,  those 
on  alternate  days  being  severe.  The  temperature  often  reaches  its 
highest  point  at  the  third  paroxysm.  The  disease  generally  runs  its 
course  in  from  nine  to  twelve  days,  but  it  may  last  much  longer. 
The  type  of  fever  may  change  to  intermittent,  which  is  a  favorable 
sign,  or  become  continued  and  again  remittent,  or  remain  remittent 
throughout;  finally,  the  fever  may  subside  gradually,  or,  less  com- 
monly, by  crisis.     The  urine  is  febrile,  but  not  albuminous. 

Pernicious  Malarial  Fever.  This,  as  the  name  implies,  is  a 
form  of  malarial  fever  with  destructive  tendency.  It  is  also  called 
malignant  and  congestive  fever.  It  may  be  intermittent  or  remittent. 
Nearly  24  per  cent,  of  the  cases  occurring  in  the  U.  S.  Army  from 
May  1,  1860,  to  June  20,  1866,  proved  fatal. 

Bemiss1  divides  it  into  three  classes  :  (1)  the  algid,  or  congestive 
form;  (2)  the  comatose  form;  (3)  the  hemorrhagic  form.  To  this 
another  class,  (4)  the  gastro-enteric  form,  may  be  added.  It  is  impor- 
tant to  remark  that  the  first  paroxysm  does  not  usually,  in  any  of 
these  forms,  indicate  that  the  type  of  the  disease  is  pernicious.  The 
first  seizure  may,  however,  prove  fatal. 

1.  The  algid  form,  according  to  Bemiss,  occurs  more  frequently  than 
any  other,  its  perniciousness  being  due  to  an  aggravation  of  the  cold 
stage  of  an  intermittent  attack.  The  patient  is  extremely  weak,  with 
cold  extremities,  pinched  features,  blue  lips,  and  faint  voice.  Respira- 
tion is  shallow,  the  pulse  rather  slow,  feeble,  and  irregular;  he  is  further 
exhausted  by  vomiting  and  liquid,  offensive  diarrhoea,  the  passages 
sometimes  being  involuntary.  There  may  be  copious  perspiration,  but 
the  internal  temperature  is  very  high.  The  mind  may  be  clear,  or 
there  may  be  deep  stupor.  Unless  speedy  relief  can  be  afforded,  the 
attack  ends  fatally. 

2.  In  the  comatose  form  the  patient  is  completely  unconscious,  the 
skin  hot  "and  of  a  muddy,  semi-jaundiced  hue"  (Bemiss).  Both 
pulse  and  temperature  are  increased.  In  other  cases  coma  is  preceded 
by  wild  delirium,  resembling  acute  meningitis. 

The  comatose  form  is  most  apt  to  occur  in  those  who  continue  to 
reside  in  a  malarious  region  without  proper  safeguards  against  its 
poisonous  influences. 

3.  In  the  hemorrhagic  form  there  has  been,  as  a  rule,  previous  alter- 
ation of  the  blood,  the  bloodvessels,  and  other  tissues,  by  long- 
continued  malarial  poisoning  or  cachexia.  Then,  when  intense  con- 
gestion of  these  parts  occurs  as  the  result  of  the  surface-chill,  hemor- 
rhage follows.  In  some  districts,  however,  and  at  certain  seasons,, 
there  has  been  a  special  predilection  of  the  poison  for  the  kidney,  with 
resulting  hematuria.  The  prominent  symptoms  are  a  prolonged  chill 
with  high  temperature;  nausea  and  vomiting,  sometimes  with  the  ex- 
pulsion of  a  greenish-black  fluid;  oedema  of  the  lower  extremities; 
general  anasarca  and  occasionally  oedema  of  the  lungs,  and  hydro- 
thorax;    bloody  and  albuminous  urine  with  tube-casts;   and  intense 

1  Pepper's  System  of  Medicine,  1885,  vol.  i.  666. 
52 


818  SPECIAL  DIAGNOSIS. 

jaundice.  Pain  in  the  right  hypochondriuni  or  over  the  kidneys  is 
common. 

Bemiss  asserts  that  uncomplicated  malarial  fever  has  not  a  hemor- 
rhagic tendency. 

4.  The  g astro-enteric  form  has  for  its  prominent  symptoms  nausea, 
vomiting,  diarrhoea,  intense  thirst,  extreme  restlessness,  a  frequent, 
feeble  pulse,  and  urgent  dyspnoea.  "The  breathing  is  deep-drawn; 
to  each  expiration  succeed  two  respirations"  (Da  Costa).  The  patient 
is  cold  and  partly  collapsed.     Reaction  may  or  may  not  occur. 

The  patient  may  have  several  paroxysms  of  pernicious  malarial 
fever,  and  succumb  in  any  one  of  them.  Convalescence  is  slow.  The 
most  frequent  sequelae  of  malarial  fevers  are  anaemia,  neuritis,  and 
paralyses,  and  malarial  cachexia. 

Typhoid  fever  is  distinguished  from  pernicious  malarial  fever  by  its 
gradual  onset,  the  absence  of  chills  and  vomiting,  as  a  rule,  and,  on 
the  other  hand,  the  presence  of  epistaxis,  delirium,  and  ataxic  symp- 
toms, tympanites  and  diarrhoea  with  pale-yellow  watery  stools,  and 
rose-colored  spots.  The  temperature  in  typhoid  is  more  continuously 
high,  the  daily  oscillations  being  of  shorter  range.  A  history  of 
exposure  to  malarial  infection  and  of  previous  attacks  can  often  be 
obtained.  The  urine  of  typhoid  exhibits  the  diazo-reaction,  that  of 
malarial  fever  does  not. 

Malarial  cachexia  occurs  especially  in  those  who  have  lived  for  a 
long  time  in  malarious  regions.  They  may  or  may  not  have  had  typical 
malarial  attacks.  The  patient  suffers  with  dyspepsia  and  constipation, 
with  occasional  bilious  attacks;  the  face  is  of  a  pale  lemon-yellow  color, 
and  may  be  slightly  jaundiced;  there  is  marked  anaemia,  with  pigment 
and  crescentic  and  flagellate  forms  of  plasmodia  in  the  blood,  together 
with  great  enlargement  of  the  spleen  (ague-cake)  and  some  enlarge- 
ment of  the  liver.  The  patient  is  weak  and  languid,  and  sometimes 
has  considerable  mental  depression. 

Yellow  Fever. 

An  acute,  specific,  contagious,  miasmatic  disease,  endemic  and  epi- 
demic on  the  tropical  and  subtropical  shores  of  the  Atlantic  Ocean, 
characterized  by  a  sudden  onset,  a  duration  of  a  week  or  less,  a  char- 
acteristic facies,  a  fall  in  the  pulse-rate  preceding  a  fall  in  temperature, 
and  by  albuminuria,  jaundice,  and  vomiting,  with  a  tendency  to 
hemorrhages. 

Yellow  fever  is  endemic  in  Havana  and  other  seaport  cities  of  Cuba, 
and  in  Rio  Janeiro,  Brazil.  From  these  centres  it  is  liable  to  become 
epidemic,  and  to  be  carried  in  ships  and  by  persons  and  clothing  to 
other  places.  In  this  way  epidemics  have  developed  in  the  seaports 
of  the  United  States,  especially  in  the  south  around  the  Gulf  of  Mex- 
ico, but  sometimes  as  far  north  as  Philadelphia  and  New  York.  The 
disease  becomes  epidemic  in  the  hot  season  and  ceases  upon  the  appear- 
ance of  frost.     The  specific  germ  has  not  yet  been  isolated. 

In  countries  in  which  the  disease  is  endemic  it  is  the  custom  to 
regard  the  native  children  as  immune.     Dr.  John  Guiteras,  however,  is 


THE  INFECTIOUS  DISEASES.  819 

strongly  of  the  opinion  that  the  disease  is  kept  alive  between  epidemics 
by  cases  among  these  very  children.  He  has  also  shown  that  it  pre- 
vails among  white  children  before  it  becomes  epidemic  among  adults. 

The  period  of  incubation  varies  from  a  few  hours  to  two  weeks. 
Guiteras  states  that  the  cases  in  which  it  extends  beyond  the  seventh 
day  are  exceptional. 

The  invasion  is  abrupt,  and  occurs  usually  in  the  night.  It  is  marked 
by  chilliness  oftener  than  by  a  decided  chill.  The  temperature 
rises  rapidly  to  102°  to  103°  or  104°,  not  often  higher  in  favorable 
cases.  The  pulse  is  correspondingly  increased  in  frequency  at  first, 
but  very  commonly  begins  to  fall  before  the  temperature,  so  that  later 
the  pulse  is  relatively  slow.  The  face  is  peculiar  and  characteristic 
— it  is  flushed  and  somewhat  swollen;  the  eyelids  are  somewhat  swol- 
len, with  reddened  edges;  the  eyes  are  watery,  glistening,  and  slightly 
but  distinctly  tinged  with  yellow;  the  pupil  is  small  and  brilliant. 
Guiteras  says  •}  "  The  appearance  of  the  face  is  often  sufficiently  char- 
acteristic on  the  first  day  of  the  disease  to  warrant  a  positive  diagno- 
sis." He  also  says  that  these  phenomena  are  often  better  observed  at 
a  slight  distance  than  on  close  inspection. 

The  tongue  is  large,  moist,  and  coated  with  white  fur.  The  stomach 
is  irritable  and  the  epigastrium  tender.  Nausea  with  repeated  vomit- 
ing occurs.  The  fluid  is  at  first  of  a  light  greenish-yellow,  subse- 
quently becoming  decidedly  bilious.     The  bowels  are  constipated. 

The  urine  almost  invariably  contains  albumin  at  some  time  during 
the  first  three  days.  Its  presence  may  be  very  transient.  It  may  be 
found  in  the  evening  and  not  at  other  times.  The  amount  of  albumin 
is  sometimes  very  large,  and  abundant  blood  and  tube-casts  are  found. 
The  nephritis  subsides  rapidly,  without  leaving  traces.  The  urine  is 
acid  in  reaction  and  scanty  in  amount.     It  is  sometimes  suppressed. 

During  this  febrile  period  the  patient  complains  of  headache,  pains 
in  the  back  and  limbs,  and  intense  thirst.  The  mind,  however,  is 
usually  perfectly  clear.  Contrary  to  expectation,  Guiteras  asserts  that 
the  nervous  symptoms  are,  perhaps,  more  prominent  in  the  adult  than 
in  the  child.  "  The  loquacity,  the  short-cut  phrases  and  precipitate 
speech,  the  excitement,  the  show  of  indifference  with  unmistakable 
evidences  of  fear — all  these,  that  are  such  prominent  features  of  the 
disease  in  the  adult,  are  absent  in  the  young."2 

In  from  two  to  five  days  the  temperature  falls  to  or  below  normal, 
headache  and  pains  in  the  limbs  disappear,  and  the  patient  is  cheerful 
and  thinks  himself  convalescent.  This  is  the  fact  in  mild  cases,  but 
in  more  severe  cases  there  is  a  return  of  symptoms  in  a  few  hours  or 
at  most  a  day  or  two.  The  jaundice  deepens,  vomiting  becomes  more 
urgent  and  in  adults  is  accompanied  by  much  retching.  It  is  bilious, 
streaked  with  blood,  or  thick  and  wholly  black  ("  black  vomit");  the 
temperature  may  rise  again  as  high  as,  or  higher,  than  in  the  original 
paroxysm,  or  it  may  remain  depressed.  In  any  event  the  pulse  is  apt 
to  be  slow,  often  from  40  to  60.      The  urine  contains  albumin,  blood, 

1  "  Report  of  the  Surgeon-General  of  the  Marine-Hospital  Service,  1888 ;"  Keating's  Cyclopaedia 

of  Diseases  of  Children,  1889,  vol.  i. 

2  Keating's  Cyclopaedia,  loc.  cit. 


820 


SPECIAL  DIAGNOSIS. 


and  casts,  and  may  be  suppressed,  adding  uraemia  to  the  other  toxaemia. 
Convulsions  at  this  stage  are  usually  ursemic.  Hemorrhages  may  occur 
from  any  mucous  surface.  The  gums  are  tender,  swollen,  and  bleed 
easily.  There  may  be  epistaxis,  hemorrhage  from  the  ear,  bowel, 
uterus,  or  vagina.  Pregnant  women  miscarry.  Ecchymoses  also  may 
form.  Death  may  take  place  in  coma  or  convulsions.  If  the  patient 
linger  beyond  the  fifth  or  sixth  day,  he  sinks  into  a  typical  typhoid 
state,  with  diarrhoea  and  marked  adynamia,  from  which  he  may  or 
may  not  emerge. 

As  in  scarlet  fever,  the  patient  may  be  smitten  down  and  die  in  a  few 
hours  from  the  time  he  was  in  apparent  health.  In  other  grave  cases 
the  temperature  remains  high,  and  rises  instead  of  falls  on  the  third 
or  fourth  day.  The  duration  of  the  disease  is  from  two  to  five  or  six 
days;  if  a  typhoid  state  develop,  it  may  last  ten  days  or  two  weeks. 

Complications  are  not  common.  Phlebitis  and  lymphangitis  occur, 
and  Guit6ras  says  he  has  noticed  hepatitis,  insanity,  and  paralysis 
(probably  from  neuritis).      Second  attacks  are  extremely  uncommon. 

Diagnosis.  Yellow  fever  is  distinguished  from  pernicious  malarial 
fever  by  the  slow  pulse,  the  characteristic  facies,  the  early  transient 
albuminuria,  the  deep  jaundice,  the  absence  of  diarrhoea,  the  occurrence 
of  black  vomit,  the  tendency  to  hemorrhage,  and  the  clear  mind. 


Fig.  161. 


Case  of  actinomycosis. 


Actinomycosis. 

A  specific  infectious  disease  of  cattle,  occurring  occasionally  in  man, 
attacking  especially  the  lower  jaw,  lungs,  and  intestine,  and  character- 
ized by  a  long  duration,  by  the  development  of  tumors  and  metastatic 
growths,  and  by  pyaemic  symptoms. 


THE  INFECTIOUS  DISEASES.  821 

It  is  due  to  the  actinouayces  or  ray-fungus  (see  Fig.  161),  which  pro- 
duces in  cattle  the  disease  known  as  big  or  lumpy  jaw  and  swelled  head. 
The  fungus  is  conveyed  in  the  food  or  drink,  and  gains  entrance  to 
the  body  through  abrasions  in  the  mouth  or  a  decayed  tooth,  or  is 
inspired  into  the  lungs. 

At  the  seat  of  invasion  a  slowly  growing,  slightly  painful  tumor 
develops.  Bones  are  affected  as  well  as  soft  tissues.  These  become 
swollen  and  suppurate,  the  fungus  being  at  all  times  obtainable.  The 
fungous  masses  appear  to  the  unaided  eye  as  particles  of  yellow  sand, 
and  are  greasy  to  the  touch.  When  the  lungs  are  involved  the  symp- 
toms are  those  of  purulent  bronchitis  or  phthisis,  actinomyces  being 
found  in  the  sputa.  The  masses  which  form  upon  the  intestinal  mucous 
membrane  may  lead  to  suppuration  and  perforation  of  the  intestine. 
Metastasis  to  any  organ  may  occur,  with  resulting  local  symptoms. 
The  duration  depends  upon  the  organs  involved  in  metastases.  If 
metastases  do  not  lead  to  early  death,  that  result  is  brought  about  at 
the  end  of  months  or  years  by  slow  pyaemia,  with  resulting  amyloid 
degeneration  and  its  consequences.  The  prognosis  depends  upon  early 
recognition  and  complete  removal  of^the  diseased  tissues. 

Glanders. 

An  infectious,  constitutional  disease,  transmitted  from  horses  to  man, 
appearing  in  an  acute  and  chronic  form,  and  characterized  by  an  erup- 
tion, ozama,  small  tumors,  ulcerations,  cough,  and  death  in  coma  or 
collapse  in  from  one  to  four  weeks  in  the  acute  form,  or  in  three  or 
four  months  in  the  chronic  form,  the  symptoms  in  the  latter  resembling 
at  times  syphilis  and  at  times  tuberculosis. 

The  disease  is  rare  in  man.  It  may  be  acquired  by  direct  inocula- 
tion of  an  open  wound  with  the  pus  from  a  glanderous  ulcer  or  nasal 
mucous  membrane,  or  indirectly  from  infected  straw  or  other  material. 
The  raw  meat  of  a  glandered  animal  also  has  infective  power. 

In  acute  glanders  the  onset  is  marked  by  headache,  slight  fever,  and 
pains  in  the  limbs.  If  a  wound  has  been  infected,  this  becomes  pain- 
ful, swollen,  and  behaves  like  any  poisoned  wound.  Sometimes  a 
diffuse  redness,  resembling  erysipelas,  spreads  from  the  infected  point. 
Fagge  refers  to  a  case  in  which  the  first  complaint  was  of  pain  in  the 
side  and  dyspnoea,  so  that  acute  pleuro-pneumonia  was  suspected. 

An  eruption,  consisting  first  of  papules,  which  rapidly  become  flat 
vesicles  and  then  pustules  or  bulla?,  appears  in  the  first  day  or  two,  or 
sometimes  not  for  a  week  or  even  longer  (Fagge).  The  bullae  or  pus- 
tules rupture  and  give  vent  to  a  thin  purulent  discharge. 

There  may  be  hard,  painful  lumps  in  the  muscles,  with  subsequent 
suppuration  (farcy). 

Ozaena  is  not  always  present.  It  appears  in  the  second  or  third 
week  of  the  disease.  It  consists  of  a  muco-purulent,  then  purulent, 
foetid  discharge  from  the  nose.  The  latter  subsequently  swells  and 
becomes  red  and  very  painful.  Ulcers  and  even  necrosis  of  the  sep- 
tum are  the  lesions;  the  same  catarrhal  condition  may  exist  in  the 
throat,  eye,  larynx,  and  mouth,  accompanied  at  times  by  ulcers  and 


822  SPECIAL  DIAGNOSIS. 

false  membrane.  The  patient  gradually  sinks  into  a  septicemic  con- 
dition, with  irregular  fever,  dry  brown  tongue,  albuminuria,  delirium, 
coma,  and  collapse. 

The  duration  of  the  acute  form  is  from  one  to  four  weeks.  Only 
one  in  thirty -eight  cases  collected  by  Bollinger  ended  in  recovery. 

In  the  chronic  form  there  are  ulcers  upon  the  hand,  face,  forehead, 
or  elsewhere.  In  other  cases  the  lesions  are  abscesses  in  connection 
with  joints  which  are  followed  by  persistent  fistulse.  In  still  other 
cases  there  is  pustular  eruption.  Ozaena  may  or  may  not  exist.  In 
still  other  cases  the  prominent  symptoms  are  cough,  bloody  expectora- 
tion, hoarseness,  fever,  and  emaciation.  Bollinger  reports  seventeen 
recoveries  in  a  total  of  thirty-four  cases  of  chronic  glanders. 

Diagnosis.  Acute  glanders  is  distinguished  from  rheumatism  by 
the  history  of  the  case,  the  occupation  of  the  patient,  the  existence  of 
an  open,  irritable  sore  and  the  fact  that  while  the  joints  may  be  pain- 
ful, they  are  rarely  red  and  swollen,  as  in  rheumatism.  Subsequently 
the  appearance  of  pustules,  bullae,  and  ozaena  makes  the  case  clear. 

The  same  peculiar  features  serve  to  distinguish  it  from  pyaemia, 
malignant  pustule,  and  other  infectious  diseases. 

In  a  suspected  case  of  chronic  glanders,  a  correct  diagnosis  might 
be  arrived  at  by  inoculating  a  mule  or  a  horse  with  the  nasal  mucus 
or  pus  from  a  farcy. 

Anthrax. 

Anthrax,  malignant  pustule,  charbon,  splenic  fever,  etc. ,  are  names 
given  to  an  acute  infectious  disease  derived  principally  from  herbiv- 
orous animals,  and  characterized  by  the  development  of  a  pustule  or 
boil,  with  extensive  brawny  oedema  and  subsequent  toxaemia;  or  toxae- 
mia may  appear  first  and  metastatic  abscesses  subsequently.  The  dis- 
ease also  attacks  the  gastro-intestinal  mucous  membrane  and  the  lung*. 

Anthrax  is  caused  by  the  anthrax-bacillus  and  its  toxins.  Outside 
the  body  it  forms  endogenous  spores,  which  are  extremely  tenacious  of 
life,  and  to  which  infection  is  invariably  due.  They  infect  not  only 
the  carcasses  of  animals,  but  also  the  soil,  all  utensils  used  in  the  care 
of  the  animals  or  the  soil,  and  they  persist  with  infective  power  in 
the  hides,  hair,  hoofs,  and  wool  ("  wool-sorter's  disease  ").  It  is  pos- 
sible that  it  may  be  transmitted  to  man  by  stings  of  insects,  particu- 
larly flies  and  mosquitoes. 

The  period  of  incubation  varies  from  a  few  hours  to  several  days. 
In  the  form  known  as  malignant  pustule  the  patient  has  a  pricking  or 
burning  feeling,  which  may  lead  him  to  think  he  has  been  stung  by 
an  insect  at  some  exposed  part  of  the  body,  particularly  the  hand,  face, 
or  neck.  At  the  seat  of  irritation  first  a  papule,  then  a  vesicle,  devel- 
ops. The  vesicle  may  attain  considerable  size.  The  contained  fluid 
quickly  passes  from  clear  to  bloody,  and  then  escapes,  leaving  a  dark- 
brown  or  black  scab  (anthrax). 

The  original  vesicle  may  be  surrounded  by  a  series  of  smaller  ones. 
Instead  of  disappearing,  the  base  of  the  vesicle  becomes  inflamed  and 
indurated,  the  induration  extending  to  surrounding  tissue  and  causing 


THE  INFECTIOUS  DISEASES.  823 

a  condition  of  brawny  oedema.  A  whole  arm  or  one  side  of  the  face 
and  neck  may  be  swollen.  There  may  or  may  not  be  an  associated 
lymphangitis. 

The  general  health  does  not  suffer  at  first,  but  in  a  day  or  two  fever 
sets  in,  accompanied  by  delirium,  sweating,  great  weakness,  enlarge- 
ment of  the  spleen,  severe  pains  in  the  limbs,  and  diarrhoea.  Death, 
preceded  by  collapse,  may  occur  in  from  five  to  eight  days  (Fagge),  or 
the  tissue  occupied  by  the  pustule  may  slough  out. 

Bollinger  and  others  have  called  attention  to  anthrax  oedema,  in 
which  there  is  no  pustule,  but  only  a  yellowish  or  greenish  swelling  of 
the  tissues.     It  is  seen  most  frequently  in  the  eyelids. 

Anthrax  of  the  gastro-intestinal  mucous  membrane,  as  described  by 
Bollinger,  presents  the  following  symptoms :  the  patient  first  complains 
of  malaise,  Joss  of  appetite,  pains  in  the  limbs,  giddiness,  and  headache. 
Then  vomiting  may  set  in,  and  a  more  or  less  severe  diarrhoea,  the 
evacuations  often  containing  blood.  There  may  be  pain  in  the  abdo- 
men, which  becomes  somewhat  tumid;  the  spleen  is  enlarged.  Dysp- 
noea and  lividity  appear,  with  restlessness  and  with  excitement  or 
stupor.  Epileptiform  convulsions  may  occur,  the  upper  limbs  may  be 
affected  with  tetanic  spasms,  there  may  be  opisthotonos,  and  the  pupils 
may  be  widely  dilated.  The  pyrexia  is  slight,  and  death  is  preceded 
by  extreme  collapse.  The  duration  of  the  disease  is  usually  from  two 
to  seven  days,  but  sometimes  it  is  scarcely  twenty-four  hours. 

Still  another  form  of  anthrax  occurs  among  the  wool-sorters  of  Brad- 
ford, England;  it  is  characterized  by  intense  dyspnoea  and  a  feeling  of 
oppression  or  constriction.  Breathing  is  labored,  but  not  much  accel- 
erated. Only  a  few  coarse  rales  are  to  be  heard  on  auscultation. 
The  expectoration  may  be  abundant  and  bloody,  or  absent.  There  is 
a  tendency  to  collapse,  with  cold,  bluish  skiu,  and  a  subnormal  axillary 
temperature.  The  rectal  temperature,  however,  is  raised  two  or  three 
degrees.  Death  may  occur  in  coma  and  convulsions,  or  suddenly,  the 
mind  being  clear.  The  duration  of  the  disease  is  from  one  to  five  days. 
Dr.  Bell  says  that  those  who  survive  for  a  week  generally  recover. 

Bacillus  Anthracis.  This  is  found  in  the  pus  of  the  lesions  of 
anthrax  or  malignant  pustule. 

Morphology.  A  bacillus,  2  to  3/x  up  to  20  to  25//  in  length  and  1 
to  l\fj.  in  breadth.  The  bacilli  are  often  joined  end  to  end  in  long- 
threads,  and  these  threads  are  massed  together  in  bundles.  As  found 
in  animals  they  are  short  rods  with  square  ends.  They  stain  best  with 
Loffler's  blue,  but  also  with  the  basic  anilines  and  by  Gram's  method. 
AVhen  in  the  stage  of  spore-formation  the  threads  look  like  strings  of 
beads. 

Biological  Properties.  It  is  aerobic,  non-motile,  and  liquefies  gelatin 
(see  Plate  II.,  Fig.  2,  a;  Plate  XI.,  Fig.  1;  and  Fig.  162). 

It  grows  best  in  neutral  or  slightly  alkaline  media  (gelatin,  agar, 
milk,  meat-infusion,  etc.)  at  20°-38°  C.  The  growth-limits  are  12° 
and  45°  C. 

Cultures  on  agar  arc  quite  characteristic,  consisting  of  a  dense  central 
mass  with  twisting  and  crossing  bundles  all  around  it.  In  gelatin  stab- 
cultures  a  fine  branching  thread  work  grows  out  alongside  the  puncture. 


824 


SPECIAL  DIAGNOSIS. 


The  gelatin  soon  liquefies  and  the  bacilli  settle  in  white  masses.  The 
growth  is  abundant  on  potato,  and  is  grayish,  dry,  rough,  and  irreg- 
ular. The  virulence  is  attenuated  by  cultivation.  Drying  does  not 
kill  the  spores.  Very  toxic  substances  are  found  in  the  culture-medium. 
When  inoculated,  the  organism  produces  the  pustule  of  anthrax. 

Anthrax-bacilli  are  not  so  numerous  in  human  blood  as  in  that  of 
the  lower  animals.  They  are  most  likely  to  be  found  in  the  spleen, 
which  is  apt  to  be  much  swollen. 


Bacillus  anthracis  in  the  blood  of  a  guinea-pig.    X  1040.    (Gibbes.) 

Diagnosis.  In  doubtful  cases  a  mouse  or  guinea-pig  should  be 
iuoeulated  with  the  blood.  Carbuncle  is  distinguished  by  its  tendency 
to  develop  upon  the  back  or  shoulders,  and  other  covered  portions; 
anthrax  on  uncovered  portions.  In  carbuncle  there  is  a  series  of  open- 
ings resembling  a  sieve,  filled  with  pus  and  plugs  of  necrotic  tissue. 
In  anthrax  there  is  at  first  a  central  black  crust.  The  boggy  feeling  of 
carbuncle  is  different  from  that  of  the  brawny  oedema  of  anthrax. 
Finally,  in  carbuncle,  anthrax -bacilli  are  not  found  in  the  blood. 

The  intestinal  and  thoracic  forms  are  distinguished  by  the  occupation 
of  the  patients,  the  absence  of  other  adequate  cause,  and  the  result  of 
the  blood-examination,  cultures,  and  inoculation-experiments. 

Foot-and-mouth  Disease. 


A  specific,  infectious  disease,  communicated  to  man  through  cattle, 
sheep,  or  pigs,  and  characterized  by  a  stomatitis.  It  is  communicable 
by  milk;  the  period  of  incubation  is  from  three  to  five  days.  Inva- 
sion is  characterized  by  slight  fever,  heat,  and  soreness  of  the  mouth, 
and  the  development  of  vesicles,  which  burst  and  leave  shallow  ulcers. 
Saliva  is  freely  poured  out.  The  tongue  swells  greatly,  and  eating  is 
painful.  Vesicles  sometimes  appear  about  the  fingers,  but  not  upon 
the  feet.  The  disease  lasts  from  one  to  two  weeks,  and  ends  almost 
invariably  in  recoverv. 


THE  INFECTIOUS  DISEASES.  825 


Hydrophobia. 

An  acute,  specific  disease  communicated  to  human  beings  by  the 
bites  of  animals  similarly  affected.  The  animals  most  frequently 
affected  are  the  dog,  fox,  wolf,  cat,  and  skunk;  90  per  cent,  of  the 
cases  in  human  beings  are  due  to  dog-bites. 

The  period  of  incubation  is  uncommonly  long  and  very  variable — 
from  two  weeks  to  two  months  usually.  It  is  said  in  some  cases  to  be 
a  year  or  more.  The  disease  has  been  divided  into  three  stages — the 
melancholic,  the  spasmodic,  and  the  paralytic. 

In  the  melancholic  stage  there  is  pain,  hyperesthesia,  or  even  reop- 
ening of  the  healed  wound.  The  patient  is  extremely  depressed  in 
spirits  and  may  be  irritable.  He  seems  to  be  laboring  under  a  constant 
tension  of  fear,  and  is  keenly  sensitive  to  light,  sounds,  or  draughts. 
He  is  affected  with  thirst,  but  attempts  to  swallow  water  cause  intensely 
painful  spasm  of  the  larynx. 

The  second  stage  is  reached  usually  on  the  second  day.  The  laryn- 
geal spasms  are  increased  and  lead  to  intense  dyspnoea  and  to  pitiable 
struggling  and  gasping  on  the  part  of  the  patient.  In  addition  to  the 
convulsive  seizures,  the  patient  foams  and  froths  at  the  mouth,  and 
his  face  expresses  the  extreme  terror  and  mental  anguish  he  feels. 
The  second  stage  lasts  from  one  to  three  days,  and  is  followed  by 
the  third  stage,  exhaustion  intermitting  with  paroxysms  of  less  severity. 
The  patient  may  iioav  be  able  to  swallow  easily,  but  there  is  great  weak- 
ness of  the  heart,  and  death  may  occur  from  failure  of  the  heart,  from 
asphyxia,  or  in  a  convulsion.  The  duration,  as  indicated,  is  only  a 
few  days.  The  result  is  practically  always  fatal,  but  recovery  may 
be  possible.     Bites  of  the  face  are  the  most  likely  to  be  fatal. 

The  Plague. 

An  acute,  specific,  infectious,  and  contagious  disease,  occurring  in 
epidemics,  characterized  by. high  fever,  sometimes  by  petechia?  and 
other  hemorrhages,  and,  in  cases  which  last  long  enough,  by  buboes. 
The  death-rate  is  extremely  high. 

The  plague  is  a  disease  of  the  East,  being  endemic  in  some  parts 
of  India,  but  epidemics  have  occurred  in  Italy,  Russia,  China, 
Turkey,  England,  and  other  parts  of  Europe. 

The  period  of  incubation  is  from  two  to  seven  days.  The  invasion 
is  marked  by  lassitude,  languor,  headache,  and  dizziness.  The  stupid 
aspect  and  staggering  gait  may  lead  to  the  belief  that  the  patient  is 
drunk.  Chill  or  chilliness  soon  supervenes,  followed  by  fever,  which 
often  rises  to  hyperpyrexia,  and  is  accompanied  by  unquenchable  thirst, 
ami  sometimes  nausea  and  vomiting.  Delirium  and  a  typhoid  condi- 
tion follow,  with  a  marked  tendency  to  failure  of  the  circulation  and 
collapse.  If  the  patient  survive  until  the  second  or  third  day,  gland- 
ular swellings  develop  in  the  groin,  or  axilla,  or  angle  of  the  jaw. 
Often  they  have  to  be  sought  for  to  be  found.  Sometimes  they  are 
prominent  and  are  followed  by  suppuration  and  even  ulceration. 
Carbuncles  are   much   rarer   manifestations  than  buboes.      Petechia?, 


826  SPECIAL  DIAGNOSIS. 

vibices,  hemorrhages  into  the  kidney,  bloody  vomit,  occur  in  the  worst 
cases. 

The  duration  is  from  six  to  ten  days.  If  there  is  much  suppuration, 
convalescence  is  prolonged. 

Leprosy. 

A  chronic,  specific,  infectious  disease,  characterized  by  the  develop- 
ment of  tubercles,  anaesthetic  patches,  and  neuritis,  and  followed  by 
ulceration  and  destruction  of  tissue.  The  disease  occurs  especially 
from  puberty  to  the  thirtieth  year,  and  oftener  in  men  than  in  women. 
It  develops  slowly  and  insidiously.  Sometimes  the  first  skin  lesion  is 
a  crop  of  bullae,  suggestive  of  pemphigus.  More  commonly  there 
appear  reddish  or  violet-colored  patches,  varying  in  size  from  a  quarter 
of  an  inch  to  two  or  three  inches  in  diameter,  and  becoming  of  a  darker 
hue  later.  The  next  step  is  the  formation  of  nodules,  which  are  char- 
acteristic of  the  disease.  These  may  develop  upon  the  patches  already 
described,  or  in  other  places.  They  vary  in  size  from  a  pea  to  a  bird's 
egg  or  larger.  They  are  most  common  upon  the  face  and  extensor 
surfaces  of  the  arms,  legs,  fingers,  and  toes.  The  tubercles  consist  of 
an  infiltration  into  the  true  skin;  they  are  raised,  firm,  relatively  pain- 
less, and  vary  in  color  from  red  to  copper.  The  face  is  characteris- 
tically distorted  into  a  fierce  expression  (leontiasis).  The  tubercles 
may  become  absorbed  and  leave  atrophic  areas,  but  generally  they 
break  down  into  eroding  ulcers,  which  slowly  burrow  and  increase 
in  extent,  eating  off  a  portion  of  the  nose,  fingers,  hands,  and  feet, 
and  exposing  muscles,  tendons,  nerves,  bloodvessels,  and  bone. 
Tubercles  form  also  upon  nerve-trunks,  and  ulcers  upon  mucous 
membranes. 

In  other  cases,  or  in  combination  with  the  tubercles,  especially  upon 
the  limbs  and  trunk,  there  are  anaesthetic  areas.  Ulcers  may  follow 
without  the  previous  occurrence  of  tubercles.  With  the  anaesthetic 
patches  are  associated  crops  of  bullae,  and  neuritis. 

The  further  peculiarities  of  the  disease  are:  its  long  duration;  its 
slow  progress  interrupted  by  apparent  healing  of  some  of  the  ulcers; 
its  afebrile  course  (the  temperature  is  generally  subnormal);  its  com- 
parative painlessness,  and  the  slight  impairment  of  the  general  health. 
Death  results  from  gradual  wasting,  or  is  hastened  by  some  intercur- 
rent affection. 

The  specific  cause  of  the  disease  is  probably  the  bacillus  leprae  of 
Hansen.  It  is  found  in  the  thin  pus  of  the  ulcers  and  in  the  lesions 
themselves.  It  consists  of  rods  4  to  6//  long  and  1/y.  broad,  closely 
resembling  tubercle-bacilli.  They  may  be  distinguished  by  yielding 
their  color  more  readily,  and  by  taking  easily  aniline-dyes  in  simple 
watery  solution  (Von  Jaksch).     (See  Plate  II.,  Fig.  4,  b.) 

The  diagnosis  from  a  tubercular  syphilide  is  made  by  the  history  of 
the  case,  the  possibility  of  infection,  the  bacteriological  examination, 
the  slow  progress,  and  the  inadequacy  of  specific  treatment.  The 
presence  of  anaesthesia  and  of  neuritis  points  to  leprosy. 


THE  INFECTIO  US  DISEASES.  827 


Miliary  Fever. 


Miliary  fever,  or  sweating-sickness,  is  an  infectious  disease,  occurring 
in  epidemics,  and  characterized  by  moderate  fever,  profuse  sweating, 
tenderness  and  a  sense  of  oppression  at  the  epigastrium,  and  a  vesicular 
eruption.  The  disease  has  occurred  epidemically  in  England,  but  is 
not  met  with  now  outside  of  France  and  Italy. 

After  mild  prodromal  symptoms  the  disease  sets  in  suddenly  with 
moderate  fever,  profuse  sweating,  and  epigastric  distress  sometimes 
amounting  to  anguish.  The  characteristic  eruption  appears  on  the 
third  or  fourth  day.  It  consists  first  of  small  reddish  rnaculse,  in  the 
centre  of  which  a  vesicle  develops.  The  latter  varies  in  size  from  a 
pinhead  to  a  pea.  The  contents  are  at  first  clear,  but  subsequently 
become  purulent.  Desiccation  and  desquamation  follow.  The  erup- 
tion is  most  profuse  generally  upon  the  neck  and  trunk.  Sometimes 
there  are  marked  nervous  symptoms,  and  even  convulsions  and  fatal 
collapse. 

It  is  distinguished  from  rheumatism  by  the  moderate  fever  and 
absence  of  joint-swellings,  and  from  malarial  fever  by  the  absence  of 
chills,  of  periodicity  in  the  febrile  movement,  and  absence  of  malarial 
organisms  from  the  blood. 

The  duration  of  the  disease  is  from  one  to  four  weeks.  The  mor- 
tality in  some  epidemics  has  been  very  high,  in  others  very  low. 

Milk-sickness. 

An  acute  disease  affecting  cattle,  and  transmitted  from  them  to 
human  beings  in  the  milk  or  meat.  The  disease  is  limited  to  a  few 
sparsely  settled  localities  west  of  the  Allegheny  Mountains.  It  is  char- 
acterized by  great  debility,  with  muscular  tremor  upon  motion  (hence 
the  name  "trembles"),  vomiting  (hence  called  "puking  fever"),  a 
peculiar  fcetor  of  the  breath,  obstinate  constipation,  and  moderate 
fever  or  subnormal  temperature.  The  vomited  matters  are  said  to  be 
of  a  peculiar  soapy  material  of  yellowish  or  greenish  color.  The  dura- 
tion is  usually  less  than  a  week.  The  patient  may  sink  into  a  typhoid 
condition  and  die  in  coma,  or  he  may  die  in  a  few  hours.  Convales- 
cence is  protracted. 

Trichinosis. 

An  acute,  infectious  disease,  caused  by  absorption  of  trichime  spiralis, 
and  characterized  by  gastric  and  intestinal  irritation,  followed  by  pain 
and  stiffness  in  voluntary  muscles,  oedema  of  the  eyelids,  face,  and 
feet,  by  profuse  sweating,  and  by  death  or  tardy  convalescence. 

The  trichinse  are  absorbed  by  human  beings  through  raw  or  imper- 
fectly cooked  food,  often  in  the  form  of  sausage.  The  trichina?  are 
encysted  when  absorbed,  but  within  forty-eight  hours  they  are  liberated 
in  the  intestine  and  can  be  found  adherent  to  the  mucous  membrane. 
In  the  course  of  six  or  seven  days,  each  liberated  female  worm  pro- 
duces about  180  embryos,  which  immediately  penetrate  the  walls  of 


828  SPECIAL  DIAGNOSIS. 

the  intestine  and  travel  or  are  carried  to  all  parts  of  the  body,  becom- 
ing in  turn  encysted. 

Swallowing  of  trichinous  flesh  does  not  necessarily  produce  symp- 
toms; the  trichinae  may  be  destroyed  in  the  stomach,  or,  if  calcified, 
may  pass  through  the  intestine  unchanged.  When  symptoms  result 
the  severity  depends  upon  the  number  of  trichinae  which  become  liber- 
ated. The  symptoms  are  sleeplessness,  lassitude,  anorexia,  nausea, 
vomiting,  tenderness  over  the  abdomen,  and  diarrhoea.  The  symp- 
toms may  be  so  severe  as  to  cause  death  in  two  or  three  days.  If 
the  patient  survive,  toward  the  end  of  the  week  the  voluntary  muscles 
become  stiff,  painful,  and  contracted.  The  muscles  feel  hard  and  swol- 
len. The  eyelids,  face,  and  sometimes  the  feet  become  oedematous. 
Depending  upon  the  muscles  involved,  there  are  interferences  with  the 
eye-movements,  contractions  of  the  jaw-muscles,  difficulty  in  breathing 
or  in  swallowing,  etc.  The  calves  of  the  legs  are  especially  involved. 
Recurrent  oedema  over  the  affected  muscles,  eyelid,  and  face  is  very 
common  and  characteristic.  Profuse  sweating  also  is  very  common, 
and  at  times  there  are  severe  neuralgic  pains. 

The  fever  is  usually  moderate,  but  it  may  be  high.  The  pulse  is 
very  frequent  if  trichinae  reach  the  heart.  The  later  stages  in  fatal 
cases  are  marked  by  insomnia,  delirium,  stupor,  and  coma. 

The  duration  varies  from  a  few  days  to  four  or  five  weeks  or  even 
longer.  Muscular  pains  may  persist  for  months  after  recovery.  Death 
results  from  exhaustion,  or  from  some  complication,  as  pneumonia  or 
ulceration  of  the  large  intestine. 

Diagnosis.  It  is  distinguished  from  typhoid  fever  by  the  presence 
of  vomiting,  and  oedema  of  the  face  and  eyelids,  the  development  of 
muscular  troubles,  by  the  absence  of  hebetude,  delirium,  and  other 
typhoid  symptoms,  and  absence  of  the  characteristic  eruption  and  en- 
largement of  the  spleen. 

Muscular  rheumatism  is  distinguished  by  being  limited  to  one  part, 
as  the  lumbar  region,  arm,  or  chest;  by  its  appearance  following  ex- 
posure to  draught;  and  by  the  fact  that  it  is  not  preceded  by  nausea, 
vomiting,  and  diarrhoea,  nor  accompanied  by  oedema. 

Constitutional  Syphilis. 

Constitutional  syphilis  may  be  acquired  or  congenital. 

Acquired  syphilis  is  characterized,  first,  by  the  initial  lesion,  or 
chancre,  which  appears  usually  in  a  week  after  contagion;  second,  by 
a  period  of  incubation  generally  lasting  six  weeks,  but  varying  from 
one  to  three  months;  third,  by  so-called  secondary  symptoms,  com- 
prising febrile  symptoms,  polymorphous  skin-eruptions,  ulcers  upon 
the  tonsils,  adenitis,  less  frequently  mucous  patches  in  the  mouth,  or 
condylomata  about  the  anus,  iritis  and  retinitis,  and  loss  of  hair.  The 
lesions  of  this  period  are  symmetrical.  Fourth,  after  an  interval 
varying  from  several  months  to  twenty  years,  by  so-called  tertiary 
phenomena,  which  manifest  themselves  in  some  cases.  These  are  due 
to  chronic  inflammatory  indurations  of  the  skin  and  subcutaneous 
tissue,  resulting  in  suppuration  aud  ulceration;  or  of  the  bones,    pro- 


THE  INFECTIO  US  DISEASES.  829 

during  periostitis  and  necrosis;  or  of  organs,  producing  gumraata  and 
cirrhosis;  or  of  the  nervous  system,  resulting  in  gummata  or  chronic 
degenerative  changes.      The  lesions  of  this  period  are  unsymmetrical.1 

The  course  of  syphilis  in  different  persons  varies  as  widely  as 
any  of  the  eruptive  fevers.  In  some  the  chancre  is  a  mere  papule 
which  heals  almost  unnoticed;  no  secondary  symptoms  appear,  and  ter- 
tiary symptoms  also  are  altogether  wanting,  or  a  chronic  degeneration  of 
the  nervous  system  develops  after  the  lapse  of  many  years,  the  patient 
in  the  meantime  remaining  in  apparent  health.  All  this  may  occur,  too, 
without  the  aid  of  specific  treatment.  In  other  cases  the  disease  is 
malignaut;  tertiary  symptoms  appear  very  early  or  appear  to  take  the 
place  of  secondary  symptoms;  ulceration  may  rapidly  melt  down  and 
destroy  the  alee  of  the  nose  or  the  soft  palate;  or  rebellious  periostitis 
with  necrosis  may  attack  the  tibiae,  the  nasal  bones,  or  the  cranium. 

In  an  ordinary  case  of  acquired  syphilis,  in  about  six  weeks  after 
the  appearance  of  the  chancre  the  patient  complains  of  languor,  weari- 
ness, slight  fever,  pains  in  the  bones,  impaired  digestion,  and  a  ten- 
dency to  anaemia.  An  eruption  now  appears.  It  is  most  marked  on 
the  trunk  and  upper  extremities,  especially  the  chest  and  forehead 
(corona  Veneris).  The  eruption  may  be  roseolous,  squamous,  vesico- 
papular,  papular,  pustular,  bullous,  or  tubercular.  The  color  has 
been  aptly  compared  to  that  of  a  slice  of  raw  ham.  The  enlarge- 
ment of  the  inguinal,  epitrochlear,  and  post-cervical  glands,  which 
precedes  the  eruption,  persists.  Shallow  ulcers  with  a  sharply  defined 
grayish  outline  appear  on  both  tonsils.  They  are  painless  and  do  not 
spread.  Ulcers  are  also  liable  to  appear  upon  the  pharynx,  buccal 
surfaces,  tongue,  angles  of  the  mouth,  penis,  vulva,  vagina,  and  around 
the  anus.  In  the  mouth  these  are  apt  to  be  very  painful,  and  may 
persist  in  spite  of  treatment  for  weeks  or  months.  Relapses  are  not 
uncommon.  Sometimes  there  are  raised  white  patches  upon  the  phar- 
ynx. Sometimes  the  hair  becomes  very  thin  and  falls  out,  leaving  the 
patient  without  eyebrows  and  more  or  less  bald.  Iritis  and  retinitis  are 
usually  later  symptoms.  Other  symptoms  occasionally  occurring  at 
this  stage  are  periostitis,  usually  slight,  and  onychia. 

The  most  common  of  the  symptoms  enumerated  are  the  eruption  and 
the  tonsillar  ulceration. 

The  eruption  comes  out  gradually  during  two  or  three  weeks  and 
persists  for  about  two  months.  Rarely,  however,  it  is  fleeting,  or,  on 
the  other  hand,  is  unduly  prolonged. 

The  secondary  symptoms  last  from  six  to  eighteen  months.  After 
their  disappearance  the  patient  may  remain  entirely  well  for  life.  In 
other  cases  after  apparent  health,  lasting  for  months  or  years,  the  ter- 
tiary phenomena  already  mentioned  appear.  In  the  interval  the  patient 
may  have  suffered  with  various  local  skin  eruptions  or  with  ulcers 
upon  the  buccal  mucous  membrane. 

For  a  description  of  the  tertiary  lesions  of  syphilis,  see  works  upon 
surgery,  and  other  articles  in  this  book  upon  visceral  diseases  in  the 
causation  of  which  syphilis  is  a  factor. 

1  Fever  is  a  constant  accompaniment  of  all  forms  of  syphilis.    (See  Fever.) 


830  SPECIAL  DIAGNOSIS. 

Hereditary  syphilis  differs  in  some  respects  from  the  acquired  form. 
At  birth  the  syphilitic  infant  usually  exhibits  no  evidence  of  its  inher- 
ited taint.  In  the  course  of  from  one  to  twelve  weeks  it  develops  a 
catarrhal  inflammation  of  the  nasal  mucous  membrane,  which  causes 
snuffling  in  breathing,  and  hence  is  called  "  snuffles."  An  eruption 
soon  appears,  symmetrical  in  distribution.  It  is  most  frequently  ery- 
thematous or  papular,  but  it  may  be  squamous,  vesicular,  pustular,  or 
bullous.  In  hereditary  syphilis  it  is  more  apt  to  be  moist  and  to  favor 
the  genitalia  and  flexures  of  the  thigh  than  in  acquired  syphilis.  It 
is  of  the  same  ham-color  as  in  acquired  syphilis.  Coincideut  with  the 
"  snuffles"  and  eruption  appear  stomatitis  and  ulcers  at  the  angles  of 
the  mouth,  and  sometimes  condylomata  around  the  anus.  Meantime 
the  child  has  begun  to  waste,  to  be  peevish,  to  be  anaemic,  and  gradu- 
ally to  assume  the  appearance  of  a  wizened,  dried-up  old  man.  As  in 
acquired  syphilis,  there  may  be  iritis,  though  it  is  uncommon,  and 
inflammation  of  the  other  structures  of  the  eye,  but  nodes  and  disease 
of  the  liver  are  rare.  The  infant  very  frequently  dies  during  this 
period  from  exhaustion  and  inanition. 

If  the  child  survive  for  a  year,  the  secondary  symptoms  usually  dis- 
appear and  the  disease  becomes  latent.  Relapses  may  occur,  and  in 
them,  according  to  Mr.  Hutchinson,  condylomata  are  likely  to  appear. 
The  same  observer  states  that  the  tertiary  period  may  begin  at  any 
time  after  the  fifth  year,  but  it  is  commonly  delayed  till  about  the 
period  of  puberty.  In  the  meantime  the  patient  may  appear  fairly 
well,  but  usually  his  development  is  retarded,  there  is  a  tendency  to 
anaemia,  and  he  has  often  naso-pharyngeal  catarrh,  flattening  of  the 
bridge  of  the  nose,  premature  decay  of  the  upper  incisor  teeth,  and 
protuberant  forehead. 

The  teeth  may  be  perfectly  normal,  in  other  cases  characteristically 
syphilitic.  The  malformation  affects  especially  the  upper  central 
incisors  of  the  permanent  set.  It  was  first  described  by  Mr.  Hutch- 
inson. It  "  consists  in  a  dwarfing  of  the  tooth,  which  is  usually  both 
narrow  and  short,  and  in  the  atrophy  of  its  middle  lobe.  This  atrophy 
leaves  a  single  broad  notch  (vertical)  in  the  edge  of  the  tooth,  and 
sometimes  from  this  notch  a  shallow  furrow  passes  upward  in  both 
anterior  and  posterior  surfaces  nearly  to  the  gum.  This  notching  is 
usually  symmetrical.  It  may  vary  much  in  degree  in  different  cases  ; 
sometimes  the  teeth  diverge,  and  at  others  they  slant  toward  each  other  " 
(see  Fig.  98  ). 

Further,  the  patient  may  have  had  or  may  now  be  attacked  with 
keratitis,  affecting  both  eyes,  producing  cloudy  opacities  aud  accom- 
panied by  great  photophobia.  Agaiu,  there  may  be  nodes  upon  the 
long  bones,  with  nocturnal  exacerbations  of  pain.  Cerebral  deafness, 
according  to  Hutchinson,  is  not  rare,  but  cerebral  blindness  is.  There 
may  be  ulceration  upon  the  legs,  and  periostitis  and  necrosis.  The 
patient  usually  recovers  completely,  but  he  is  more  liable  to  be  carried 
off  by  intercurrent  disease  than  a  healthy  person,  and  in  general  has 
less  resisting  power,  especially  to  tuberculosis. 


THE  INFECTIOUS  DISEASES.  831 

Diagnosis.  The  diagnosis  of  hereditary  syphilis  is  based  upon  the 
occurrence  of  snuffles  and  skin-eruptions,  and  the  existence  of  keratitis 
or  of  cicatrices,  especially  about  the  angles  of  the  mouth.  A  history 
of  repeated  miscarriages  is  suggestive  of  maternal  syphilis.  The  diag- 
nosis of  acquired  syphilis  is  based  upon  the  history  of  chancre,  when 
that  history  is  obtainable;  upon  the  existence  of  polymorphous  erup- 
tions, or  of  non-traumatic  ulcers  upon  the  legs  of  young  adults,  or  of 
nodes,  or  of  alopecia  associated  with  sore-throat  or  mucous  patches. 
The  presence  of  obscure  disease  of  the  bones,  glands,  or  spinal  cord 
should  lead  to  the  search  for  a  possible  syphilitic  infection. 

Tuberculosis. 

Tuberculosis  is  an  infectious  disease,  the  course  of  which  may  be 
acute  or  chronic.  It  is  caused  by  the  bacillus  tuberculosis.  This 
micro-organism  sets  up  a  specific  inflammation  characterized  by  the 
development  of  nodules  or  tubercles,  or  by  a  diffuse  growth  of  tuber- 
culous tissue.  Either  anatomical  product  may  undergo  caseation  or 
sclerosis,  and  in  either  instance  ulceration  or  calcareous  degeneration. 

Invasion  of  the  body  by  the  micro-organism  may  give  rise  to  gen- 
eral infection,  with  an  eruption  of  miliary  tubercles  in  most  of  the 
organs  aud  structures  of  the  body,  or  to  a  local  infection.  General 
tuberculosis  is  acute;  local  tuberculosis  may  be  acute  or  chronic.  In 
acute  tuberculosis  the  serous  membranes,  the  lungs,  liver,  kidneys, 
lymphatic  glands  and  spleen,  the  bone-marrow,  and  choroid  coat  of 
the  eye  may  be  invaded  in  whole  or  in  part.  In  chronic  tuberculosis 
the  lymph-glands,  the  lungs,  the  serous  membranes,  the  tissues  and 
organs  of  the  alimentary  canal,  the  liver,  the  organs  of  the  genito- 
urinary system,  and  the  brain  and  cord  are  individually  invaded. 

The  diagnosis  of  any  form  of  tuberculosis  is  aided  by  the  determi- 
nation of  the  chief  factors  in  its  aetiology,  where  this  is  possible. 
First.  The  discovery  of  the  bacillus  tuberculosis  in  any  inflammatory 
area,  or  any  product  of  inflammation,  as  serum,  blood,  pus,  or  the 
secretion  from  any  gland  or  mucous  membrane  invaded  by  the  disease, 
establishes  at  once  the  diagnosis  of  this  condition.  The  method  of 
determining  the  presence  of  this  micro-organism  is  fully  detailed  in  the 
various  descriptions  of  tuberculosis  in  the  discussion  of  local  diseases, 
and  in  the  accounts  of  the  examination  of  the  sputum  and  of  exuda- 
tions and  transudations.  Second.  As  tuberculosis  is  an  infectious  dis- 
ease, discovery  of  the  infection  is  an  aid  in  the  diagnosis.  Infection 
takes  place  by  means  of  the  inhalation  of  the  sputum  or  other  secre- 
tions, which  when  dry  float  about  in  the  air.  It  implies  in  a  measure 
more  or  less  contact  with  individuals  previously  infected.  In  rare 
cases  such  contact  is  productive  of  the  disease  by  means  of  direct  con- 
tagion. The  second  source  of  infection  is  the  food-supply.  This  may 
occur  from  the  consumption  of  milk  secured  from  a  cow  infected  with 
tuberculosis.  The  eating  of  meat  of  tuberculous  animals  may  possibly 
lead  to  infection.  Direct  inoculation  is  another  but  rarer  source  of 
infection.  This  usually  occurs  accidentally  only.  Finally,  it  is  possi- 
ble that  tuberculosis  may  be  inherited.      A  more  prominent  etiological 


832  SPECIAL  DIAGNOSIS. 

factor,  which  aids  in  the  diagnosis  of  the  disease,  is  the  presence  of  a 
certain  type  of  structure  which  is  a  marked  hereditary  characteristic 
in  families,  on  account  of  which  feeble  resistance  is  offered  to  the 
invasion  of  the  tubercle-bacillus.  The  phthisical  and  phthisinoid 
chest  which  belongs  to  this  type  has  been  described  elsewhere,  and  the 
tuberculous  and  scrofulous  states  have  been  outlined  (see  pages  55  and 
242).  These  anatomical  conditions,  which  are  inherited,  undoubtedly 
favor  the  development  of  tuberculosis. 

It  is  a  mistake  to  lay  much  stress  in  the  diagnosis  of  tuberculosis 
upon  the  age  or  the  occupation  of  the  individual.  Tuberculosis  may 
occur  at  any  age.  It  is  true,  however,  that  at  certain  periods  of  life 
the  tubercles  are  distributed  more  commonly  in  one  group  of  organs, 
while  in  other  periods  they  affect  another  group.  Lymphatic,  joint, 
and  meningeal  tuberculosis  is  most  common  in  the  first  decade  of  life. 
The  mesenteric  glands  are  particularly  open  to  invasion  at  this  period. 

The  diagnosis  of  tuberculosis,  whether  local  or  general,  is  further 
aided  by  a  complete  knowledge  of  the  phenomena  that  attend  the 
entrance  of  the  virus  into  the  body  and  the  mode  of  diffusion  through- 
out the  body  after  infection  has  taken  place.  The  phenomena  at  the 
point  of  entrance  of  the  micro-organism  are  nearly  always  distinct. 
The  general  invasion  is  associated  with  symptoms  like  those  of  specific 
fevers.  The  local  secondary  effects  upon  the  tissues  are  always  decided. 
It  must  be  borne  in  mind  that  after  the  exposure,  which  may  lead  to 
infection,  either  an  acute  form  of  tuberculosis  of  a  general  character 
may  be  set  up,  with  or  without  marked  local  symptoms,  or  acute  local 
tuberculosis  alone  may  arise.  In  local  tuberculosis  the  disease  is  confined 
to  one  organ  or  to  the  lymphatic  glands  and  the  organs  in  the  lymphatic 
distribution,  as  the  bronchial  glands,  which  are  primarily  affected,  and 
to  the  lungs.  .  In  these  structures  the  entire  process  of  nodular  forma- 
tion, caseation  or  sclerosis,  ulceration  or  calcification,  may  take  place. 
The  disease  remains  primarily  local.  On  the  other  hand,  it  may  be 
spread  by  continuity  of  structure  through  the  lymphatics  throughout 
the  remainder  of  the  organ  affected,  leading  to  its  ultimate  destruc- 
tion and  the  death  of  the  patient;  or  general  infection  of  the  system 
may  take  place  from  the  primary  local  area.  The  primary  seat  of 
iufection  may  be  the  lungs,  the  larynx,  the  alimentary  tract,  or  the 
genito-uriuary  organs.  Primary  tuberculosis  of  the  serous  membranes, 
of  the  lymph-glands,  of  the  bones  and  joints,  may  take  place. 

The  symptomatology  and  diagnosis  of  the  various  forms  of  tubercu- 
losis are  detailed  in  the  section  devoted  to  the  special  diseases  of  the 
various  organs  of  the  body. 

Acute  miliary  tuberculosis  has  been  spoken  of  elsewhere  (see  page 
329).  Its  course  may  resemble  typhoid  fever,  septicaemia,  or  malig- 
nant endocarditis.  It  usually  develops  in  the  course  of  tuberculosis 
in  some  other  organ  of  the  body.  The  typhoid  form  has  been  described 
in  the  section  indicated.  It  must  not  be  forgotten  that  the  diagnosis 
is  rendered  positive  by  the  demonstration  of  the  presence  of  tubercle- 
bacilli  in  the  blood,  or  of  the  occurrence  of  choroidal  tubercles  in  the 
eye-ground.  Another  form  is  attended  by  marked  pulmonary  symp- 
toms.    This  is  the  type  seen  in  the  bronchial  pneumonia  that  occurs 


THE  INFECTIOUS  DISEASES. 


833 


in  children  following  measles  and  whooping-cough  (see  Catarrhal 
Pneumonia).  Of  the  pulmonary  symptoms  dyspncea  is  the  most  prom- 
inent. Cyanosis  is  marked.  The  physical  signs  are  not  prominent, 
and  may  be  those  of  bronchitis  alone.  Although  there  is  impaired 
resonance  at  the  base  of  the  lungs,  areas  of  hyper-resonance  are  ob- 
served above  and  in  front  of  the  chest.  Collapse  of  the  lung  may 
cause  tubular  breathing.  The  temperature  rises  to  102°  to  103°.  An 
inverse  type  may  be  seen. 

The  diagnosis  of  acute  tuberculosis  is  determined  by  the  history  of 
infection  from  extraneous  sources  or  from  local  tuberculosis  in  some 
portion  of  the  body,  and  by  the  presence  of  bacilli. 

The  following  conditions  should  point  to  chronic  tuberculosis  in 
some  portion  of  the  body:  1,  emaciation,  not  otherwise  explained;  2, 
anaemia;  3,  weakness  without  cause;  4,  fever — the  temperature  should 
be  taken  every  two  hours  during  night  and  day;  5,  causeless  sweats; 
6,  gastro  intestinal  catarrh;  7,  morning  nausea  ;  8,  signs  of  local  inflam- 
mation in  some  organ  of  the  body. 

Simple  Continued  Fever. 

A  non-contagious  fever,  lasting  from  one  to  twelve  days,  not  depen- 
dent upon  any  known  specific  cause  and  not  attended  with  any  definite 
local  lesions.  Its  chief  characteristic  is  the  continued  elevation  of 
temperature. 

Fig.  163. 


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Sim]jle  coniinued  fever. 

It  occurs  especially  in  children  and  in  those  prone  to  ready  disturb- 
ance of  the  heat-regulating  apparatus.  Great  mental  and  physical 
exhaustion,  prolonged  bathing  in  the  hot  sun,  and  disturbances  in 
digestion  may  cause  it.  Perhaps,  as  suggested  by  Guiteras,  some  of 
the  cases  occurring  in  the  tropics  and  in  very  hot  weather  should  be 
regarded  as  very  mild  forms  of  thermic  fever. 


834  SPECIAL  DIAGNOSIS. 

The  onset  of  the  disease  is  abrupt.  There  may  be  a  chill,  or  in 
nervous  children  a  convulsion;  but  these  are  rare.  The  temperature 
rises  rapidly  to  102°  to  104°,  accompanied  by  headache,  thirst,  rest- 
lessness or  drowsiness,  loss  of  appetite,  a  coated  tongue,  constipation, 
and  occasionally  nausea.  The  urine  is  scanty  and  sometimes  there  is 
a  heavy  deposit  of  urates.  There  may  also  be  more  or  less  muscular 
soreness.  Sometimes  within  twenty-four  or  forty-eight  hours  there  are 
free  perspiration  and  a  rapid  subsidence  of  the  fever  and  all  its  symp- 
toms.     This  is  ephemeral  fever. 

In  other  cases  the  fever  continues  for  a  week  or  ten  days  longer. 
During  this  time  the  symptoms  already  noted  continue.  Sleep  is  dis- 
turbed and  mild  delirium  is  at  times  present.  Respiration  and  pulse 
are  not  much  accelerated.  Sudamina  upon  the  abdomen  and  herpes 
on  the  lips  are  common.  Pale-bluish  maculae  are  sometimes  seen. 
The  spleen  is  not  enlarged  except  in  very  rare  cases,  and  there  are  no 
local  evidences  of  disease.  The  fever  subsides  more  gradually  than 
in  ephemeral  fever,  the  defervescence  being  marked  at  times  by  per- 
spiration, a  few  loose  stools,  a  copious  deposit  of  urates  in  the  urine, 
or  by  hemorrhages  from  the  nose,  rectum,  uterus,  or  urethra. 

The  diagnosis  from  other  fevers  and  febrile  affections  is  made  by  the 
absence  of  any  characteristic  eruption,  of  enlargement  of  the  spleen 
and  liver,  and  of  any  lesion,  such  as  endocarditis,  bronchitis,  or 
pneumonia. 


CHAPTER   XI. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

Disturbances  of  sensibility,  of  motility,  and  of  the  reflexes,  vaso- 
motor and  trophic  disturbances,  and  disturbances  of  intellection  are 
due  to  diseases  of  the  nervous  system. 

The  Disturbance  of  Sensibility. 

In  anaesthesia  there  is  absence  of  sensibility.  In  hyper  cesthesia  the 
sensibility  is  abnormally  increased,  so  that  even  slight  irritation  may 
produce  painful  sensations.  The  word  hyperesthesia  is  employed 
when  sensation  is  diminished  but  not  entirely  lost.  Parcesthesice  are 
abnormal  sensations  in  the  skin,  as  formications,  numbness,  pricking, 
etc.,  also  called  symptoms  of  sensory  irritation.  Actual  pain  may  be 
one  of  the  symptoms  of  sensory  irritation.  Such  abnormal  sensations 
are  due  to  a  morbid  condition  of  the  nerve  itself. 

Cutaneous  sensibility  is  of  several  varieties,  and,  hence,  to  determine 
any  change,  the  various  forms  of  sensation  must  be  tested.  In  ner- 
vous diseases  one  variety  of  sensation  may  be  destroyed  while  others 
remain  intact.  Such  abnormal  changes  are  known  as  partial  anaes- 
thesia or  paralyses  of  sensation.  The  following  varieties  of  cutaneous 
sensibility  are  to  be  tested  : 

1.  Tactile  Sensibility.  Tactile  sensibility  is  tested  by  touching  the 
skin  with  the  finger  or  a  blunt  object.  The  patient's  eyes  being  closed, 
he  is  asked  whether  he  has  felt  the  touch  or  not.  It  is  well  sometimes 
to  control  the  experiment  by  asking  the  question  without  touching  the 
skin.  The  opposite  side,  which  is  presumed  to  be  healthy,  should  be 
tested  in  the  same  way,  for  purposes  of  comparison.  The  patient  is 
told  to  close  his  eyes,  and  when  familiar  objects,  such  as  coins,  keys, 
or  geometrical  figures  are  placed  in  his  hand  he  is  asked  to  describe 
their  shape  and  external  characteristics — whether  they  are  hard  or  soft, 
rough,  round,  or  angular.     This  is  known  as  stenognosis. 

2.  Sense  of  Locality.  When  any  part  of  the  surface  of  the  body  is 
touched  we  can,  under  normal  conditions,  tell  the  exact  locality  of  the 
point  of  contact.  The  ability  to  localize  the  sensation  is  sometimes  lost 
by  patients  with  nervous  diseases.  The  tactile  sense  may  be  tested 
directly  by  means  of  the  hands,  the  patient  designating  the  point 
touched,  or  by  means  of  compasses,  By  the  latter  method  the  patient 
is  subjected  to  two  simultaneous  irritations  of  the  skin  at  the  same  time. 
The  points  of  the  compass  may  be  distinguished  as  separate  irritants 
at  from  11  to  15  mm.  on  the  cheeks,  6  mm.  at  the  tip  of  the  nose,  1.2 
mm.  at  the  tip  of  the  tongue,  etc.  At  the  tips  of  the  fingers  the  two 
points  can  be  detected  at  from  2  to  3  mm.;  on  the  thigh,  77  mm. 


836  SPECIAL  DIAGNOSIS. 

Various  modifications  of  this  test  must  be  employed  to  control  the 
results,  as  by  bringing  down  one  point  at  a  time,  or  at  a  different  place 
each  time. 

3.  Sense  of  Pressure.  The  sense  is  tested  by  putting  the  hand  on  a 
firm,  hard  surface,  as  a  table,  and  placing  graduated  weights  upon  it. 
The  test  may  be  roughly  tried  by  pressing  upon  the  skin  with  the  hand 
or  a  pencil,  using  various  degrees  of  force. 

4.  Sense  of  Temperature.  Thermic  sensibility  is  tested  by  the  appli- 
cation of  hot  and  cold  bodies  alternately.  The  sensations  to  heat  and 
cold  are  due  to  distinct  functions,  and  therefore  may  be  separately 
modified.  The  heat-sense  may  be  abnormal,  while  the  cold-sense  is 
unchanged.  If  the  sense  of  temperature  is  impaired,  the  application 
of  either  hut  or  cold  objects  may  not  be  perceived  at  all.  The  sense 
may  be  blunted,  so  that  hot  water  feels  as  if  it  were  only  tepid;  or  it 
may  be  lost  entirely,  the  patient  perceiving  the  touch,  but  not  the 
temperature  of  the  object  applied.  In  partial  anaesthesia  to  cold  the 
application  of  a  bit  of  ice  may  be  described  as  causing  a  warm  sensa- 
tion. Only  differences  of  temperature  are  recognized  by  this  sense. 
In  health  a  difference  of  one  degree  Fahrenheit  is  usually  distinguished 
without  difficulty.  The  temperature-sense  may  be  tested  by  the  use 
of  vials  filled  with  water  at  varying  temperatures. 

5.  Sensation  of  Pain.  Loss  of  tactile  sensibility  does  not  necessarily 
imply  loss  of  sensation  of  pain.  The  former  may  be  lost,  while  pain 
is  readily  excited  in  the  affected  area.  The  loss  of  sensibility  to  pain 
is  known  as  analgesia.  It  is  of  common  occurrence  in  both  peripheral 
and  central  nervous  diseases.  The  point  of  a  pin,  thermal  irritants, 
induced  electrical  currents,  or  pinching  of  the  skin  are  methods  used 
to  determine  the  sensation  of  pain. 

6.  Electro^cutaneous  Sensibility.  This  is  determined  by  faradiza- 
tion, but  does  not  give  any  more  accurate  information  than  is  secured 
by  testing  the  tactile  sense  and  the  pain-sense. 

7.  Delayed  Conduction  of  Sensation.  In  certain  diseases  the  patient 
does  not  respond  to  the  irritant  until  an  appreciable  interval  has  elapsed 
after  the  application.  This  delay  of  conduction  is  seen  particularly 
in  locomotor  ataxia.  The  sensation  of  touch  may  be  several  seconds 
in  advance  of  the  sensation  of  pain. 

8.  The  Muscular  Sense.  By  the  muscular  sense  we  are  enabled 
without  the  sense  of  sight  to  tell  the  position  of  our  limbs.  A  healthy 
person  can  describe  at  once  the  direction  and  character  of  any  passive 
movements.  In  patients  with  nervous  diseases  this  faculty  may  be 
lost.  When  a  patient  is  called  upon  to  make  a  definite  movement, 
the  eyes  being  closed,  this  movement  is  not  completed,  or  is  incorrectly 
made,  if  the  muscular  sense  be  lost. 

Anaesthesia  of  the  Skin.  Any  break  in  the  conducting  path  from  the 
surface  of  the  body  to  the  centres  of  s'ensation  in  the  cerebral  cortex 
causes  anaesthesia,  either  complete  or  partial.  Anaesthesia  may  be 
peripheral,  spinal,  or  cerebral.  In  peripheral  anaesthesia  the  termina- 
tions of  the  sensory  cutaneous  nerves  do  not  respond  to  irritations. 
This  takes  place  after  the  application  of  anaesthetics,  or  of  corrosive 
substances,  as  acids  or  alkalies,  carbolic  acid,  etc.,  or  after  the  use  of 


DISEASES  OF  THE  NERVOUS  SYSTEM.  837 

cocaine  or  morphine.  Another  form  of  peripheral  anaesthesia  is  due 
to  disease  of  the  nerve-trunks  from  trauma,  from  compression  of  the 
nerve,  or  from  neuritis. 

Spinal  Ancesthesia  is  seen  in  hemorrhages,  local  softening  and 
tumors,  which  are  located  in  the  posterior  portion  of  the  internal  cap- 
sule. When  half  the  body  is  affected  it  is  known  as  hemianesthesia, 
and  is  on  the  opposite  side  of  the  lesion.  Anaesthesia  is  often  seen 
in  hysteria. 

Neuralgia. 

Neuralgia  is  characterized  by  pain  in  the  coarse  of  distribution  of  the 
affected  nerve.  The  pain  is  of  pronounced  severity,  and  occurs  in 
remissions  and  intermissions.  The  symptoms  of  a  neuralgic  par- 
oxysm may  be  preceded  by  hyperesthesia  over  the  part  subsequently 
affected.  The  pain  is  of  a  burning  or  shooting  character.  It  is 
usually  limited  to  the  distribution  of  the  affected  nerve,  but  may 
extend  into  other  regions.  It  may  be  excited  by  external  irritants,  by 
mental  excitement,  and  often  by  movement  of  the  part.  On  exam- 
ination the  area  of  distribution  of  the  affected  nerve  may  be  found  to 
be  anaesthetic,  but  usually  there  is  hyperaesthesia  of  the  skin.  Wherever 
the  affected  nerve  is  accessible  to  pressure  pain  can  be  elicited.  The 
nerve-trunk  may  be  tender  during  the  attack,  as  well  as  during  the 
intervals.  In  neuralgia  there  is  often  some  spasm  of  the  muscles 
supplied  by  the  nerve. 

Vasomotor  symptoms  are  common.  The  skin  may  be  pale,  or  red- 
dened. When  the  trigeminal  nerve  is  affected  the  skin  and  conjunc- 
tivae are  both  reddened.  The  secretions,  as  the  tears,  may  be  modified. 
Eruptions  like  urticaria  or  herpes  may  develop  along  the  course  of 
the  nerves.  Prolonged  neuralgia  may  cause  marked  nutritive  dis- 
turbances. 

General  Conditions.  A  patient  who  is  subject  to  neuralgia  may  be 
in  apparent  good  health.  The  neuralgia  may  be  due  to  constitutional 
causes,  as  rheumatism  or  gout;  to  some  form  of  toxaemia,  as  malaria; 
to  some  condition  of  the  blood,  as  anaemia;  and  may  be  due  to  trauma 
or  to  cold. 

The  following  individual  forms  of  neuralgia  are  seen:  1.  Neuralgia 
of  the  trigeminus,  or  tie  douloureux.  The  entire  fifth  nerve,  or  some 
of  its  branches  are  affected.  The  pain  is  often  severe  and  may  be 
associated  with  twitchings,  with  vasomotor  disturbances,  with  erup- 
tions, and  with  changes  in  the  secretions.  Trophic  changes,  as  the 
hair  turning  gray,  or  ulceration  of  the  cornea  may  follow.  Usually  a 
single  branch  is  affected,  either  the  first  branch  (ophthalmic),  the  second 
branch  (supra-maxillary),  or  the  third  branch  (infra-maxillary).  Points 
of  pressure  are,  as  a  rule,  readily  detected  at  the  foramina  for  the  exit 
of  the  nerves.  2.  Occipital  neuralgia.  3.  Neuralgia  of  the  brachial 
plexus.  4.  Intercostal  neuralgia.  5.  Neuralgia  of  the  lumbar  plexus, 
of  which  we  have  lumbo-abdominal,  crural,  and  obturator  neuralgia. 
This  form  of  neuralgia  (lumbar  plexus)  must  not  be  confounded  with 
bone  and  joint  disease;  with  lumbago;  renal  colic;  appendicitis,  and 
uterine  affections.      6.   Sciatica.      7.    Genital  and  rectal  neuralgia. 


838  SPECIAL  DIAGNOSIS. 

Trigeminal  neuralgia  mast  be  distinguished  from  headache  due  to 
other  causes,  affections  of  the  bones  and  periosteum,  and  affections  of 
the  teeth.  The  distribution  and  paroxysmal  character  of  the  pain  and 
the  points  of  tenderness  assist  in  the  diagnosis. 

Disturbances  of  Motility. 

Paralysis  is  a  loss  of  power  of  the  voluntary  muscles.  It  must  be 
distinguished  from  loss  of  motion  or  inhibition  of  function  due  to 
disease  of  the  muscle,  or  to  pain  on  movement. 

When  there  is  absolute  loss  of  power  the  paralysis  is  complete  ;  when 
there  is  weakness  of  the  muscles  the  condition  is  known  as  paresis,  and 
certain  movements  are  still  possible. 

Causes.  Destruction  of  the  function  of  the  motor  centres  in  the 
cerebral  cortex  and  diseases  in  any  portion  of  the  cortico-muscular 
conduction-path  may  lead  to  paralysis.  Paralysis  is  also  due  to  disease 
of  the  muscles.  It  is  known  as  myopathic  paralysis.  Paralysis  of  one 
side  of  the  body  is  known  as  hemiplegia.  One-half  of  the  face,  the 
arm  and  the  leg,  or  an  arm  and  a  leg  of  one  side  alone  are  paralyzed. 
The  trunkal  muscles  are  not  affected  in  hemiplegia.  Hemiplegia  is 
usually  of  brain  origin.  Diplegia  is  the  word  used  to  denote  paralysis  of 
two  symmetrical  portions  of  the  body,  as  both  sides  of  the  face,  diplegia 
facialis,  or  both  arms,  diplegia  brachialis.  Paralysis  of  the  lower 
transverse  half  of  the  body  is  known  as  paraplegia,  and  is  usually  of 
spinal  origin.  Monoplegia  is  facial,  brachial,  or  crural,  according  to 
the  situation  of  the  paralysis,  and  may  be  due  to  disease  of  the  brain, 
of  the  spinal  cord,  or  of  the  nerve-trunk.  Monoplegia  of  cerebral 
origin  is  nearly  always  cortical;  if  of  spinal  origin,  the  lesion  is  com- 
monly seated  in  the  ganglion-cells  of  the  anterior  cornua.  A  local 
paralysis  is  loss  of  power  of  a  single  muscle  or  a  group  of  muscles. 
AVhen  many  local  palsies  exist  it  is  known  as  multiple  paralysis.  A  local 
paralysis  is  frequently  due  to  disease  of  the  nerve-trunk— a  neuritis. 

The  symptoms  of  paralysis  are  recognized  by  the  patient's  statement 
and  by  physical  examination :  1 .  Loss  of  muscular  power.  2.  Change 
in  the  tone  and  volume  of  the  muscles.  3.  Changes  in  the  reflexes, 
the  nutrition,  and  the  sensations.  Changes  in  the  condition  of  the 
paralyzed  muscle  are  valuable  diagnostic  criteria  as  to  the  cause  of  the 
paralysis  (see  page  138).  The  paralyzed  muscle  may  retain  its  normal 
volume  and  normal  nutrition,  or  it  may  be  atrophied.  To  the  latter 
belong  the  atrophic  paralyses.  AVhen  there  is  no  atrophy  the  break 
in  the  course  of  the  motor  fibres  is  somewhere  between  the  cortex  and 
the  cells  in  the  anterior  cornua.  In  atrophic  paralyses  the  cause  lies 
in  the  ganglion-cells  or  in  the  peripheral  nerves.  The  ganglion-cells 
must  influence  the  nutrition  of  muscles.  If  the  cells  are  normal  and 
the  nerves  are  not  affected,  the  nutrition  of  the  muscles  remains  good 
for  some  time  after  the  injury.  If  the  ganglion-cells  are  involved, 
the  nerves  also  which  proceed  from  the  point  of  lesion  to  the  muscle 
may  atrophy  or  degenerate.  This  degeneration  gives  rise  to  certain 
alterations  in  the  electrical  reactions  of  the  muscles  (see  Electrical 
Diagnosis). 


DISEASES  OF  THE  NERVOUS  SYSTEM.  839 

When  passive  motion  is  performed  in  some  forms  of  paralysis  there 
is  resistance  to  the  movements  on  account  of  contraction  of  the  mus- 
cles. This  condition  is  known  as  spastic  paralysis.  When  muscular 
resistance  is  absent  these  contractions  are  known  as  flaccid  paralyses. 
Contracture  of  the  muscles  takes  place  in  long-continued  paralysis;  it 
must  not  be  confounded  with  spastic  paralyses  that  occur  in  paralytic 
conditions  of  long  standing.  A  true  shortening  of  the  muscle  takes 
place  and  the  contracture  cannot  be  overcome  by  the  application  of 
force  insufficient  to  rupture  the  tendon. 

In  paralysis  of  the  face  the  mouth  is  drawn  toward  the  sound  side, 
unless  contractures  take  place  in  the  paralyzed  muscles.  In  paralysis 
of  half  the  tongue  the  tip  turns  toward  the  paralyzed  side  when  it  is 
protruded. 

Motor  Irritation.  Motor  irritation  is  indicated  by  spasm,  which 
is  a  morbid  movement  excited  independently  of  the  will,  and  due  to 
irritation  somewhere  in  the  motor  tracts.  The  irritation  may  act 
directly  on  the  nerve-trunk,  or  on  the  peripheral  endings,  or  the  cen- 
tral nervous  system,  as  in  reflex  spasms. 

Spasms  may  be  clonic  or  tonic.  When  the  muscular  contraction  lasts 
but  a  short  time,  and  is  followed  by  relaxation,  the  two  alternating 
rapidly,  they  are  clonic  in  character.  There  is  constaut  convulsive 
movement.  In  tonic  spasm  there  is  persistent  contraction  of  the  mus- 
cle. Tonic  and  clonic  spasms  may  alternate  in  the  same  individual  or 
the  same  group  of  muscles. 

Spasms  are  also  classified  according  to  the  degree  and  character  of  the 
irritation.  They  are  all  motor  irritations.  1.  Epileptiform  convulsions 
are  clonic  or  tonic-clonic.  They  may  extend  over  the  whole  body,  or 
be  limited  to  one-half  the  body,  or  to  one  portion,  as  the  arm  or  leg. 
The  true  type  is  seen  in  epilepsy,  in  hysteria,  and  in  organic  disease 
of  the  brain.  2.  Rhythmical  contractions.  There  is  more  or  less  con- 
tinuous, moderate  contractions  of  groups  of  muscles.  They  are  seen 
in  apoplexy  and  in  cerebral  sclerosis.  They  also  occur  before  or  after 
an  epileptic  fit.  3.  Tremor.  The  spasms  are  moderate,  succeeding 
one  another  rapidly,  and  when  mo>t  severe  known  as  ' 'shaking." 
Tremors  are  large  or  small,  depending  on  the  extent  of  the  oscilla- 
tions. Tremor  is  seen  in  its  most  pronounced  form  in  paralysis  agitans. 
We  also  have  senile  tremor,  alcoholic  tremor,  hysterical  tremor,  and 
tremor  due  to  metallic  poisonings.  It  is  also  seen  in  exophthalmic 
goitre.  Tremor  without  known  cause  is  sometimes  hereditary.  Inten- 
tion-tremor is  a  condition  in  which  vibrations  occur  whenever  a  volun- 
tary movement  is  attempted,  such  as  grasping  an  object.  It  occurs  in 
multiple  sclerosis.  4.  Sudden  twitchings,  or  a  contraction  of  one  or 
more  muscles,  may  be  due  to  direct  motor  irritation,  or  be  of  reflex 
origin  in  disease  of  the  spinal  cord.  5.  Fibrillary  contractions  arc 
due  to  spasm  of  separate  fasciculi  of  the  muscles.  Such  contraction 
is  seen  in  spinal  progressive  muscular  atrophy.  6.  Choreiform  move- 
ments are  irregular  twitchings  that  simulate  to  some  extent  voluntary 
actions.  The  movements  may  be  slight  and  local,  or  general.  They 
may  be  confined  to  the  face  or  to  an  extremity,  and  they  are  usually 
interrupted  by  pauses  of  irregular  length.     They  occur  in  chorea  and 


840  SPECIAL  DIAGNOSIS. 

after  hemiplegias.  7.  Athetosis.  (See  page  134.)  Slow  involuntary 
movements,  chiefly  of  the  arm  and  hand,  of  a  worm-like  character,  occur. 
They  are  of  common  occurrence  in  the  cerebral  paralysis  of  children. 
8.  Coordinated  spasms  are  forced  complicated  movements,  as  spasms  of 
jumping,  laughing,  running,  moving  in  a  circle,  or  turning  about  the 
axis  of  the  body.  They  may  be  associated  with  spasm  of  the  respira- 
tory, pharyngeal,  and  laryngeal  muscles.  They  occur  in  hysteria,  cer- 
tain forms  of  epilepsy,  and  disease  of  the  cerebellum.  9.  Tonic  spasms. 
The  muscles  are  in  a  constant  state  of  rigidity,  as  the  muscles  of  mas- 
tication in  trismus.  Muscles  of  the  back  and  neck,  when  in  tonic 
spasm,  cause  opisthotonos.  10.  Catalepsy .  The  muscles  remain  in  any 
position  given  to  them  on  passive  movement.  Will-power  is  entirely 
lost.  Catalepsy  occurs  in  hysteria;  rarely  in  meningitis.  Sometimes 
the  muscle  enters  upon  a  low  state  of  tonic  spasm,  when  it  is  forcibly 
stretched;  this  is  known  as  paradoxical  contraction,  and  occurs  usually 
either  in  some  of  the  neuroses  or  in  paralysis  agitans. 

Convulsions  are  combined  tonic  and  clonic  spasms,  rapidly  alternat- 
ing. They  are  divided  into  epileptiform  or  cerebral  convulsions,  in 
which  consciousness  is  lost;  hysterical  convulsions,  in  which  con- 
sciousness is  disturbed;  and  spinal  convulsions,  in  which  consciousness 
is  normal  but  reflex  actions  are  exaggerated. 

Ataxia.  In  ataxia,  or  incoordination,  there  is  want  of  coordinated 
action  of  muscles  which  are  required  to  conduct  complicated  move- 
ments. Either  there  is  (1)  undue  contraction,  or  (2)  paralysis  or  pare- 
sis of  one  or  more  of  the  muscles  involved  in  the  complicated  move- 
ment, or  (3)  the  innervation  of  the  muscles  is  abnormal,  so  that  irregular 
contractions  take  place  in  the  production  of  the  movement.  The 
accomplishment  of  a  complicated  act,  as  walking,  is  known  as  coordi- 
nated movement.  When  the  muscles  do  not  act  simultaneously,  inco- 
ordination results.  Ataxia  may  involve  all  the  muscles  of  the  body 
or  only  one  of  the  extremities,  so  that  we  may  have  an  ataxia  of  the 
arm,  etc.  Ataxia  occurs  in  disease  of  the  cerebellum  and  the  spinal 
cord,  as  in  locomotor  ataxia  (see  page  60). 

The  Reflexes. 

Reflexes  are  of  two  kinds,  cutaneous  reflexes  and  tendon-reflexes. 

Cutaneous  Reflexes.  When  the  sensory  cutaneous  nerves  are  irritated 
muscular  contractions  are  excited  in  the  vicinity.  These  are  known 
as  cutaneous  reflexes.  They  are  excited  by  pricking  or  pinching  or  by 
tickling  the  skin.  The  reflexes  of  the  upper  extremities  are  not 
marked.  In  the  lower  extremities  they  are  more  pronounced.  They 
may  be  excited  by  tickling  the  soles  of  the  feet,  by  pricking  them  with 
a  pin,  or  by  the  application  of  ice  to  the  skin. 

In  nervous  diseases  there  is  often  delay  in  the  reflexes;  that  is,  there 
is  no  response  to  the  irritation  until  after  ten  or  fifteen  seconds.  The 
reflex  contractions  are  usually  confined  to  the  irritated  limb.  The  irri- 
tability may  be  so  great,  however,  as  to  cause  a  response  from  both 
legs  or  even  from  the  whole  body,  as  in  tetanus  or  in  strychnine-poison- 
ing.   The  following  are  special  forms  of  cutaneous  reflex  :  The  abdom- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  841 

inal  reflex;  the  cremaster  reflex  (the  testicle  is  drawn  up  when  the 
skin  of  the  inside  of  the  thigh  is  irritated);  the  gluteal  reflex;  the 
plantar  reflex;  the  mammillary  reflex,  etc. 

Even  within  the  bounds  of  health  variations  in  the  reflexes  occur  in 
different  individuals,  and  it  is  important,  therefore,  to  compare  the 
reflexes  on  symmetrical  portions  of  the  body. 

Cutaneous  reflexes  are  absent  in  diseases  of  the  peripheral  nerves 
and  of  the  spinal  cord,  because  the  conduction  of  the  reflex  is  inter- 
rupted in  its  course.  They  are  also  absent  when  the  reflex  centres 
lose  their  irritability,  as  in  shock.  Increase  of  the  cutaneous  reflexes 
occurs  in  strychnine-poisoning,  in  cutaneous  hyperesthesia,  and  in  gen- 
eral neuroses,  because  of  increased  irritability  of  the  parts.  In  disease 
of  the  brain  and  spinal  cord  which  causes  degeneration  of  reflex  centres 
they  are  abolished. 

Tendon-reflexes.  Muscular  contractions  occur  from  irritation  of  the 
tendons,  the  periosteum,  or  the  fasciae.  The  nerves  of  the  tendon  are 
irritated  and  excite  reflex  contraction. 

The  patellar  reflex.  This  is  detected  when  the  patient  crosses  the  leg 
loosely  over  the  opposite  knee,  or  when  it  hangs  over  the  arm  in  a 
relaxed  state.  The  tendon  of  the  patella  is  struck  by  the  finger  or 
pleximeter.  All  muscular  tension  of  the  leg  must  be  avoided.  The 
reflex  may  be  reinforced  by  simultaneous  muscular  efforc  on  the  part 
of  the  patient,  as  contraction  of  a  hand  when  the  blow  is  given. 

Ankle-clonus.  When  the  tendo  Achillis  is  made  tense  by  a  short, 
vigorous,  dorsal  extension  of  the  foot  the  reflex  is  exaggerated,  plantar 
flexion  of  the  foot  taking  place.  If  persistent  dorsal  extension  of  the 
foot  is  maintained,  it  is  followed  by  a  vigorous  tremor.  Other  reflexes 
are  obtained  in  the  lower  extremities.  They  are  elicited  by  a  blow  on 
the  periosteum  or  fasciae,  etc. 

The  tendon-reflex  is  absent  in  poliomyelitis,  locomotor  ataxia,  and 
peripheral  neuritis.  It  is  increased  in  cerebral  and  spinal  paralysis, 
when  the  lesion  affects  the  arc  above  the  segment  containing  the 
reflex. 

Vasomotor,  Trophic,  and  Secretory  Disturbances.  1.  Vasomotor 
paralysis.  This  is  indicated  by  abnormal  redness  of  the  skin,  with 
increase  in  the  temperature  and  a  sensation  of  heat.  It  occurs  in 
functional  neuroses,  as  hysteria  and  neurasthenia,  and  follows  injuries 
of  the  sympathetic  nerve.      (See  Hyperemia,  p.  177.) 

2.  Vasomotor  spasm.  There  are  pallor  and  coolness  of  the  skin, 
because  of  spasm  of  the  small  vessels.  There  are  formication  and  stiff- 
ness. It  is  most  common  in  the  hands.  It  may  give  rise  to  trophic 
disturbances,  as  in  symmetrical  gangrene,  scleroderma,  and  similar 
diseases. 

The  following  trophic  disturbances,  described  elsewhere,  are  symp- 
toms of  functional  or  organic  disease:  1.  Angio-neurotic  oedema.  2. 
Herpes  zoster.  3.  Urticaria.  4.  Atrophy  of  muscles  and  nerves. 
5.  Atrophy  of  the  skin  (see  Glossy  Fingers).  6.  Acute  bedsores. 
7.  Myxoedema.  8.  Trophic  changes  in  the  skin,  nails,  and  hair. 
9.   Acromegalia.      10.   Trophic  swellings  of  the  joints. 


842  SPECIAL  DIAGNOSIS. 


Electrical  Diagnosis. 

For  purposes  of  diagnosis  we  use  two  forms  of  current — the  faradic 
and  the  galvanic.  Practically  we  study  the  reaction  of  the  rnuscle  to 
stimulation  through  its  nerve,  for  we  cannot,  except  in  experimental 
work  upon  animals,  in  which  nerve  and  muscle  can  be  isolated,  limit 
the  action  of  the  current  to  a  muscle  without  influencing  the  nerve- 
fibres  in  it.  In  testing  a  nerve  it  will  be  found  that  the  result 
varies  according  to  the  current  used.  Thus,  if  the  two  poles  of  a 
faradic  battery  be  applied,  say,  to  the  ulnar  nerve,  there  results  a 
muscular  contraction,  the  presence  and  force  of  which  depend  upon 
the  strength  of  the  current,  and  not  upon  which  pole  is  directly  over 
the  sensitive  point.  With  the  galvanic  current  the  matter  is  more 
complicated.  If  one  large  electrode  is  placed  at  some  indifferent 
point,  say  on  the  sternum  or  between  the  scapulae,  and  the  other, 
smaller,  electrode  over  the  nerve,  and  the  current  passes,  it  will  be 
found  that,  as  long  as  the  current  is  not  interrupted,  no  contraction  of 
the  muscle  will  take  place.  If,  however,  the  current  be  interrupted, 
there  will  be  a  contraction  at  each  opening  and  closing.  But  the  oc- 
currence of  a  contraction  depends  upon  which  pole  is  over  the  nerve 
and  whether  the  current  is  opened  or  closed.  That  is,  the  strength  of 
current  needed  to  produce  a  contraction  depends  upon  whether  the 
positive  or  negative  pole  is  over  the  nerve  and  whether  the  current 
is  opened  or  closed;  in  other  words,  if  we  begin  with  a  very  weak 
current,  there  is  no  contraction  under  any  circumstances,  and  in  slowly 
increasing  it  we  find  that  the  first  contraction  occurs  when  the  nega- 
tive pole  is  over  the  nerve  and  the  current  closed.  At  the  moment  of 
opening  the  current,  and  when  it  passes  without  interruption,  there 
is  no  contraction.  If  the  current  is  increased  still  more,  the  contrac- 
tion at  closing — the  negative  pole  still  being  over  the  nerve — becomes 
stronger,  and,  as  the  current  is  increased,  contraction  will  occur  when 
the  positive  pole  is  over  the  nerve.  In  this  case  contraction  usu- 
ally appears  first  at  the  opening  and  later  at  the  closing.  If  the  cur- 
rent be  still  further  increased,  we  obtain  a  contraction  at  the  opening, 
the  negative  pole  being  over  the  nerve.  In  order  to  obtain  this  re- 
action the  current  may  need  to  be  so  strong  as  to  be  painful.  This, 
then,  is  the  order  in  which  contractions  occur  in  the  healthy  nerve  and 
muscle.  We  can  make  it  more  easily  understood  by  the  following 
formula.  Let  A.  represent  the  positive  pole  or  anode,  C.  the  negative 
pole  or  cathode,  O.  the  opening,  and  C.  the  closing.     Thus : 

Negative  closing  =  C.  C 
Positive  opening  =  A.  O. 
Positive  closing  =  A.  C 
Negative  opening  =  C.  0. 

Any  deviation  from  this  formula  denotes  disease.  For  instance,  if 
C.  O.  contraction  occurs  with  the  same  strength  of  current  as  C.  C. 
contraction,  it  would  be  conclusive  evidence  of  some  pathological 
change  in  the  nerve  or  trophic  centres.  In  certain  diseases  we  find 
distinct  and  definite  changes  in  the  reactions.   Let  us  take,  for  instance, 


DISEASES  OF  THE  NERVOUS  SYSTEM.  843 

the  peroneal  nerve  in  a  case  of  acute  anterior  poliomyelitis.  For  the 
first  few  days  after  the  onset  of  the  disease  there  will  be  a  diminishing 
response  of  the  nerve  to  both  farad ic  and  galvanic  currents.  If  the 
current  be  applied  directly  over  the  muscle,  it  will  be  found  that  the 
response  to  faradism  rapidly  decreases  and  may  be  finally  entirely  lost, 
while  the  response  to  galvanism  is  not  nearly  so  much  diminished,  and 
may,  toward  the  end  of  the  second  week,  actually  increase.  Not  only 
do  we  have  an  increase,  but  the  polar  reaction  is  changed,  so  that  A. 
C.  contraction  may  equal  C.  C.  contraction,  and  after  a  while  C.  O. 
contraction  may  equal  A.  O.  contraction,  or  C.  O.  contraction  may 
appear  with  a  less  current  than  A.  O.  contraction.  The  character  of 
the  contraction  varies  also.  In  the  healthy  muscle  it  is  quick  and 
shock-like;  in  the  diseased,  sluggish  and  worm-like.  These  altera- 
tions constitute  the  reaction  of  degeneration  (De  R.).  Finally,  the 
muscle  may  cease  to  respond  to  the  galvanic  current  no  matter  how 
strong  it  may  be. 

The  reaction  of  degeneration  often  requires  much  skill  to  determine, 
and  as  it  is  probably  never  present  in  a  muscle  which  contracts  nor- 
mally to  the  faradic  current  the  failure  of  response  to  this  current  is 
the  best  test  for  the  practitioner  as  to  the  condition  of  the  muscle  and 
nerve.  The  presence  of  reaction  of  degeneration  meaus  that  the 
lesion  is  either  in  the  nerve-trunk  (neuritis),  the  anterior  motor  cells 
of  the  cord  (poliomyelitis),  or  in  the  nuclear  origin  of  a  nerve.  It  is 
never  caused  by  a  cerebral  lesion.  In  purely  muscular  diseases,  as, 
for  example,  pseudo-muscular  hypertrophy,  there  may  be  diminution 
or  absence  of  electrical  response,  but  never  reaction  of  degeneration. 

Cerebral  and  Spinal  Localization. 

Since  the  discovery  by  Broea,  in  1861,  that  certain  disturbances  of 
speech  are  associated  with  lesions  of  the  third  left  frontal  convolution, 
and  the  discovery  by  Fritsch  and  Hitzig,  in  1870,  that  irritation  of 
certain  areas  of  the  cortex  of  the  brain  produces  movements  in  definite 
groups  of  muscles,  investigation  has  shown  that  definite  areas  of  the 
cortex  are  concerned  with  definite  functions.  Some  of  these  areas 
(centres)  are  now  well  known  and  their  localization  determined,  and  it 
is  the  purpose  of  the  present  chapter  to  study  the  symptoms  produced 
by  lesions  in  which  they  are  involved.  The  position  of  a  lesion,  then, 
is  determined  by  the  symptoms;  but  all  the  symptoms  are  not  of  equal 
localizing  value,  some  indeed  being  valueless.  All  symptoms  are  due 
either  to  destruction  or  irritation  of  nerve-tissue,  and  both  occur  in 
every  lesion.  The  former,  called  "direct,"  are  permanent  unless  sonic 
other  part  assumes  the  function  of  the  part  destroyed.  The  latter, 
called  "indirect,"  are  transitory  unless  the  lesion  be  a  slowly  increas- 
ing one,  in  which  case,  as,  for  example,  in  a  tumor,  they  recur  but  do 
not  persist.  t(  Indirect"  symptoms  are  produced  by  changes  in  circu- 
lation and  compression  around  the  focus  of  disease.  We  must  wait  for 
them  to  pass  away  before  attempting  to  localize  the  lesion.  Again 
symptoms  are  "  focal  "  or  u  diffuse."  .  The  former  are  due  to  inter- 
ference with  the  function  of  some  definite  part  of  the  brain,  while  the 


844 


SPECIAL  DIAGNOSIS. 


latter  may  be  caused  by  disease  in  any  part.  The  commonest  "  dif- 
fuse "  symptoms  are  headache,  vomiting,  loss  of  consciousness,  and 
optic  neuritis.  The  value  of  "focal"  symptoms  in  localization  de- 
pends upon  whether  they  occur  only  when  the  lesion  is  in  one  definite 
area  or  in  one  of  several.  If  the  onset  is  acute,  it  is  necessary 
to  know  that  all  the  symptoms  appeared  at  the  same  time,  as  other- 
wise they  must  have  been  caused  by  different  lesions.  In  a  chronic 
but  progressive  disease  there  is,  of  course,  gradual  increase  of  the 
symptoms. 


Cerebral  Localization. 

Cerebral  Cortex.  The  motor  area  includes  the  ascending  frontal,  the 
parietal,  and  the  posterior  portion  of  the  frontal  convolutions  and  the 
paracentral  lobule.  The  upper  third  contains  the  centre  for  the  leg  of 
the  opposite  side,  the  middle  third  that  for  the  arm,  and  the  lower 
third  that  for  the  head  and  neck.  The  centre  for  the  motor  mechan- 
ism of  speech  is  in  the  third  left  frontal  convolution. 


Fig.  164. 


Praecentral  F. 


,F.  Rolando 


Parietal  F. 


1st  Frontal  F. 


Parieto-Occipital  F. 


2nd  Frontal' F.     / 

F.Sylvius 


1st  Temporal'F. 


2nd  Temporal  F. 


Convolutions  of  the  left  hemisphere.    (L.  C  Gray  ) 

Destructive  lesions  in  this  area  cause  paralysis  of  one  limb  (mono- 
plegia), or  of  a  group  of  muscles.  In  order  that  all  the  centres  should 
be  affected,  and  palsy  of  the  opposite  half  of  the  body  (hemiplegia) 
ensue,  the  lesion  would  have  to  be  so  great  as,  in  any  acute  disease,  to 
cause  immediate  death.  If,  however,  the  lesion  is  not  confined  to  the 
gray  substance,  but  penetrates  the  white  matter,  fibres  from  healthy 
portions  of  the  cortex  may  be  interrupted  and  a  more  extensive  palsy 
result  than  is  found  in  a  purely  cortical  lesion.  Further,  a  minute 
lesion  of  the  white  matter  may,  as  shown  below,  produce  a  mono- 
plegia, and,  therefore,  palsy  of  one  extremity  does  not  prove  absolutely 
the  presence  of  cortical  disease. 

Irritative  lesions  cause  convulsive  movements   in  the  muscles  con- 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


845 


trolled  by  the  affected  part.  The  convulsions,  however,  are  often  not 
limited  to  the  muscle  in  which  they  arise,  but  extend  throughout  one 
side  or  over  the  whole  body.  Again,  while  several  centres  may  be 
diseased,  the  convulsion  may  begin  in  one  limb  or  in  one  group  of 
muscles.  In  general,  we  may  say  that  convulsion  is  of  less  localizing 
value  than  paralysis,  because  in  the  latter  case  the  seat  of  disease  must 
be  in  the  centre  itself,  or  in  the  fibres  derived  from  it,  while,  in  the 
former,  it  need  only  be  near  the  centre.  Nevertheless,  a  convulsive 
movement  in  a  paralyzed  limb  usually  indicates  a  cortical  lesion. 
General  convulsions  are,  of  course,  of  no  localizing  value. 

Pre-frontal  Lobe.  Lesions  of  the  frontal  lobe,  anterior  to  the  motor 
area,  produce  either  no  symptoms  at  all  or  purely  mental  ones,  and 
hence  it  was  formerly  held  that  this  area  was  the  seat  of  the  mind. 
It  is  now  largely  held,  however,  that  the  mind  is  an  attribute  of  the 
entire  cerebral  cortex,  and  it  is  certainly  true  that  lesion  in  any  part 
may,  if  extensive  enough,  produce  mental  symptoms. 


Fio.  165. 


Word  Blindness 


Diagram  showing  localization  of  centres  in  the  cortex.    (L.  C.  Gray.) 

Cortical  Centres  of  Speech  (Aphasia).  The  speech-centres  are  situ- 
ated in  the  third  left  frontal  and  first  temporal  convolutions  in  right- 
handed  people,  while,  curiously,  enough,  in  left-handed  people  the 
centres  are  usually,  if  not  always,  upon  the  right  sicle.  Lesion  of 
them,  or  of  the  association-path  between  them,  situated  in  the  insula(?), 
results  in  different  forms  of  affection  of  speech,  called  collectively 
aphasia.  It  must  be  remembered  that  aphasia  is  not  due  to  a  paral- 
ysis of  the  muscles  of  articulation  and  phonation,  but  to  a  mental  in- 
ability to  select  the  proper  word  or  to  determine  the  necessary  move- 
ments for  its  pronunciation. 

In  the  accompanying  diagram  from  Wernicke  the  motor  (//)  and 
sensory  (x)  speech-centres  are  represented.  If  the  lesion  is  at  y,  motor 
aphasia  results.  There  is  no  palsy  of  the  muscles  used  in  speech,  and 
the  patient  hears  perfectly  and  knows  what  he  wishes  to  say;  that  is, 
he  has  perfect  recollection  of  words,  yet  he  cannot  speak  at  all  or  can 
only  say  a  few  words  or  syllables.     There  is  often  inability  to  write 


846 


SPECIAL  DIAGNOSIS. 


(agraphia)  without  paralysis  of  the  hand  or  mind-blindness,  and  some- 
times inability  to  read  (alexia). 

If  the  lesion  is  at  x,  which  is  the  termination  of  the  centripetal  path 
of  the  auditory  nerve,  "  sensory  aphasia,"  "  word-deafness,"  results. 


Fig.  166. 


Wernicke's  schema  for  the  cortical  mechanism  of  speech. 

The  power  of  hearing  sound  is  retained,  but  the  ability  to  interpret  the 
meaning  of  spoken  words  is  lost.  If  the  lesion  is  absolute,  the  patient 
is  unable  to  repeat  words  that  he  has  heard.     He  may  have  as  large  a 


A         Mi 


m 


I 

Schema  illustrating  the  seven  different  forms  of  aphasia,  a  A,  centripetal  path  for  auditory 
impressions;  A,  centre  for  auditory  images ;  M,  centre  for  motor  images;  Mm,  centrifugal  motor 
path  ;  B,  the  place  where  concepts  are  formed ;  0,  the  centre  for  visual  images ;  E,  the  centre  from 
which  the  organs  of  writing  are  innervated.    (LichthTsim.) 

vocabulary  as  ever,  but  he  makes  mistakes  both  in  the  use  of  words 
and  in  their  forms.  The  errors  are  especially  marked  in  the  volun- 
tary revival  of  words,  while  automatic  speech,  as  in  singing  or  swear- 
ing, may  be  normal.     Nouns  are  more  apt  to  be  lost  than  verbs,  ad- 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


847 


jectives,  or  prepositions.  Circumlocution  is  often  used — for  example, 
the  patient  may  say  "  that  with  which  one  cuts,"  meaning  "  knife." 

If  the  lesion  is  between  y  and  x  in  the  insula(?),  "  amnesia,"  or 
"conduction-aphasia,"  results.  In  this  case  there  is  no  loss  in  the 
motor  speech-process  nor  word-deafness,  but  there  is  difficulty  in  recall- 
ing words,  and  they  are  used  improperly.  If  both  x  and  y  be  involved, 
there  is  "  total  aphasia."  The  patient  loses  both  power  and  under- 
standing of  speech. 

If  the  lesion  is  in  the  supramarginal  and  angular  convolutions, 
"  alexia,"  "  word-blindness,"  results.  The  patient  cannot  recall  the 
appearance  of  words  and  does  not  recognize  print  or  writing.  He 
may  be  able  to  pronounce  letters  and  can  often  write  correctly,  but 
cannot  read  intelligently  what  he  has  written.  Word-blindness  is  a 
part  of  the  larger  symptom  "  apraxia,"  mind-blindness,  in  which  the 
patient,  while  seeing  objects,  fails  to  recognize  their  nature  and  char- 
acteristics by  vision. 

A  study  of  the  above  diagram  from  Lichtheim  will  probably  make 
the  whole  subject  clearer. 


Fig.  168. 


Int.  Capsule\ 


1st  Frontal  f. 


Caudate  Nucleus 
(Head)) 


_  2nd  Frontal  f. 


Caudate  Nucleii 
(Tail) 


Optic  Radiations 


1st  Temporal  f. 


d  Temporal/. 


Pulvinar 


Cuneiis      Parieto-oceipital  f. 
Convolutions  of  the  vertex,  on  the  right;  on  the  left,  the  basal  ganglia,  internal  capsule, 
centrum  ovale,  and  the  cuneus.    (L.  C.  Gray.) 


In  apraxia  the  concept-centre  (/>)  is  affected;  in  motor  aphasia  the 
lesion  is  on  the  path  Mm ;  in  sensory  aphasia  the  lesion  is  at  A  ;  in 
alexia  the  le?ion  is  at  0;  in  conduction-aphasia  the  lesion  is  some- 
where in  the  paths  connecting  A  and  31.  In  every  case  of  suspected 
aphasia  the  following  tests  should  be  made :  1.  Ability  to  recognize 
the  nature  and  uses  of  objects.  2.  Ability  to  recall  the  names  of 
things  seen,  smelled,  tasted,  touched,  or  heard.  3.  Ability  to  under- 
stand  spoken  words.     4.   Ability   to  understand  printed  or  written 


848 


SPECIAL  DIAGNOSIS. 


words.  5.  Ability  to  understand  musical  tunes.  6.  Power  of  volun- 
tary speech.  7.  Ability  to  read  aloud  and  understand  what  he  reads. 
8.  Ability  to  write  and  understand  what  he  has  written.  9.  Ability 
to  copy  writing  or  print.  10.  Ability  to  write  from  dictation.  11. 
Ability  to  repeat  words  heard. 

It  must  be  remembered  that  the  problem  is  much  more  complex  at 
the  bedside  than  it  appears  here.  The  cases  are  often  not  clearly  dif- 
ferentiated, but  various  types  run  into  each  other,  and  the  severity  of 
the  symptoms  varies  greatly. 

Parietal  Lobe.  Extensive  disease  probably  interferes  with  sensation 
on  the  opposite  side  of  the  body.  The  functions  of  the  ascending 
parietal  and  of  the  paracentral  lobules  have  already  been  described. 

Occipital  Lobe.  The  cortical  centre  of  vision  is  in  the  cuneus  and 
the  adjacent  convolutions.  Disease  in  it  produces  hemianopsia,  which 
is  described  under  a  special  heading. 

Corpus  Oallosum.  No  localizing  symptoms  occur  in  disease  in  this 
region.  Mental  dulness  and  bilateral  weakness  result  sometimes  from 
tumor.  The  centrum  ovale  contains  fibres  from  the  cortex  which  come 
closer  together  and  occupy  a  smaller  and  smaller  space  until  the  internal 
capsule  is  reached.  It  follows,  therefore,  that  the  nature  of  the  symp- 
toms will  vary  with  the  distance  of  the  lesion  from  the  cortex.  If  near 
the  cortex,  the  symptoms  must  resemble  those  found  in  corresponding 
cortical  disease;  while  if  near  the  internal  capsule,  they  will  in  turn 


Fig.  169. 


Callosomarginal  f. 


Parieto-occipita  I  f. 


Calcarine  f. 


Mwmmillary  Body' 


Optic  Tract 
interior  Commissure 


Vertical  section  through  the  centre  of  the  corpus  callosurn,  showing  the  convolutions 
of  the  median  surface  of  the  hemisphere.    (L.  C  Gray.) 


resemble  the  symptoms  of  disease  in  that  region.  Thus  a  lesion  under 
one  of  the  motor  centres  produces  a  monoplegia,  while  a  deeper  one 
will  result  in  hemiplegia.  Local  convulsions  will  occur  only  when 
there  is  an  irritative  lesion  immediately  below,  in,  or  pressing  upon 
the  cortex.  If  the  lesion  is  extensive,  there  may  he  hemiansesthesia 
on  the  opposite  side.  Disease  of  the  white  matter  of  the  occipital 
lobe  may  cause  hemianopsia;  of  the  temporal  lobe,  auditory  disturb- 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


849 


ance.     The  differential  diagnosis  between  a  cortical  and  a  subcortical 
lesion  is  often  difficult  and  sometimes  impossible. 

The  internal  capsule  is  the  most  frequent  seat  of  cerebral  disease, 
the  lesion  being  most  often  vascular— embolism,  or  rupture  of  an 
artery.  If  the  lesion  is  situated  in  the  anterior  third,  between  the 
caudate  nucleus  and  the  lenticular  nucleus,  no  definite  symptoms  re- 
sult, so  far  as  known;  but  if  it  is  in  the  middle  third,  we  have  hemi- 
plegia of  the  common  type.  The  lower  face,  the  arm,  and  the  leg  on 
the  opposite  side  are  all  affected,  and,  if  the  palsy  is  of  the  right  side, 
there  is  in  the  beginning  defect  of  speech.  There  may  also  be,  at 
first,  deviation  of  the  head  and  eyes,  but  never  permanent  palsy  of 
any  crauial  nerve.  Later  on  rigidity  develops  in  the  muscles,  the 
knee-jerk  is  increased,  and  ankle-clonus  appears.  Sometimes  the  hemi- 
plegia is  not  complete,  for,  if  the  lesion  is  small,  many  fibres  may 
escape,  but  there  is  practically  never  a  true  monoplegia.  The  sensory 
fibres  from  the  cortex  pass  through  the  posterior  third,  and  conse- 
quently, if  it  is  to  be  involved,  hemianesthesia  results,  and  there 
may  be  hemianopsia  and  loss  of  smell  on  the  anaesthetic  side. 


Fig.  170. 


Diagram  to  show  the  relative  position  of  the  several  motor  tracts  in  their  course  from  the  cortex 
to  the  crus.  The  section  through  the  convolutions  is  vertical ;  that  through  the  internal  capsule. 
I  C,  horizontal;  that  through  the  crus  is  again  vertical.  C  N,  caudate  nucleus;  O  TH,  optic 
thalamus  ;  L  2  and  L  3,  the  middle  and  outer  parts  of  the  lenticular  nucleus;  fa  I,  face,  arm,  and 
leg  fibres.    The  words  in  italics  indicate  the  corresponding  cortical  centres.    (Gowers.) 

The  Corpus  Striatum  and  Optic  Thalamus.     Lesions  of  the  corpus 
striatum  present  no  diagnostic  symptoms  unless  the  internal  capsule  is 

54 


850 


SPECIAL  DIAGNOSIS. 


involved.  Lesions  of  the  optic  thalamus  are  frequently  associated 
with  hemiathetosis  or  hemichorea;  hemianopsia  occurs  particularly 
when  the  pulvinar  is  involved,  and  Nothnagel  has  called  attention  to 
the  absence  of  expression  (paralysis  of  mimicry)  in  the  opposite  side 
of  the  face. 

The  Corpora  Quadrigemina  are  closely  connected  with  the  optic- 
nerve  fibres,  the  tegmentum,  the  superior  and  middle  cerebellar 
peduncles,  the  pineal  gland,  the  pulvinar,  and  the  nuclei  and  fibres 
of  the  ocular  nerves.  In  consequence,  disease  in  this  region  is  accom- 
panied by  numerous  and  varying  symptoms.  Ataxic  gait,  similar  to 
that  present  in  cerebellar  disease,  ophthalmoplegia,  and  nystagmus  are 
somewhat  characteristic  symptoms;  impairment  of  hearing  frequently 
occurs,  especially  when  the  posterior  pair  of  the  corpora  quadrigemina 
are  involved. 

The  Crus  Cerebri  is  in  close  anatomical  relation  with  the  oculomotor 
nerve,  as  is  shown  in  the  diagram.  "We  find,  therefore,  characteristic 
symptoms  when  it  is  diseased.  There  is  always  oculomotor  palsy  on 
the  same  side  as  the  lesion,  and  hemiplegia  on  the  opposite  side,  both 
coming  on  at  once.  If  there  is  anaesthesia  on  the  palsied  side,  the  teg- 
mentum is  also  involved. 

Fig.  171. 


Cross-section  through  the  region  of  the  anterior  corpora  quadrigemina.  qu.a.,  anterior  corpora 
quadrigemina  ;  g.c,  gray  matter  around  the  aqueduct  of  Sylvius ;  nil!,  nucleus  of  the  third  nerve  ; 
hi,  posterior  longitudinal  bundle ;  r.k.,  red  nucleus  (tegmentum) ;  s  n,  substantia  nigra  (locus  niger)! 
p,  cerebral  peduncle.    (Hirt.) 


Pons.  The  symptoms  depend  upon  the  level  at  which  the  lesion  is 
situated.  The  fibres  of  the  facial  nerve  decussate  higher  up  than 
those  of  the  pyramidal  tract,  and,  cons'equently,  a  lesion  in  the  lower 
part  will  cause  facial  palsy  on  the  same  side,  and  palsy  of  the  leg  and 
arm  on  the  opposite  side  (alternating  paralysis).  If  the  lesion  is  above 
the  facial  nerve  decussation,  hemiplegia  of  the  opposite  side,  including 
the  face,  will  result;  such  hemiplegia  indistinguishable,  however,  from 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


851 


the  typical  hemiplegia  due  to  disease  of  the  internal  capsule  by  the  fact 
that  all  the  branches  of  the  facial  are  affected,  and  that  there  may  be, 
though  rarely,  reaction  of  degeneration.     Bilateral  lesions  may  cause 


Fig.  172. 


Diagram  showing  the  decussation  of  the  fibres  going  to  the  extremities,  and  of  those  going  to  the 
face  in  the  pons  and  medulla  oblongata.  F,  facial  fibres ;  E,  fibres  going  to  the  extremities ;  P, 
pons  ;  0,  medulla  oblongata  ;  pyx,  decussation  of  the  pyramidal  tracts  ;  a,  a  focus  in  the  upper ; 
b,  a  focus  in  the  lower  part  of  the  pons  (the  latter  is  situated  below  the  decussation  of  the  facial 
fibres).    (Hiet.) 

bilateral  facial  palsy,  or  bilateral  palsy  of  the  legs  or  of  all  four  ex- 
tremities.    The  local  diagnosis  in  such  cases  is  usually  very  difficult. 


Fig.  173. 


Diagram  showing  the  different  tracts  of  the  cord.    (Gowers.) 

Convulsions  often  occur  in  acute  lesions.     There  is  sometimes  anes- 
thesia in  the  area  of  the  trifacial. 


852 


SPECIAL  DIAGNOSIS. 


Fig.  174. 


Ci 


Cerebellum.     The  hemispheres  may  be  extensively  diseased  without 
giving  rise  to  any  symptoms.     The  characteristic  symptoms  of  disease 

of  the  middle  lobe  are  disturbance  of  equi- 
librium and  incoordination.  The  gait  re- 
sembles that  of  a  drunken  man.  Giddiness 
and  vomiting  sometimes  occur,  but  are  of 
no  localizing  value.  Nystagmus  is  fre- 
quent in  cases  of  tumor.  The  knee-jerk  is 
often  absent,  or  it  may  be  sometimes  absent 
and  sometimes  present.  If  the  pyramidal 
tracts  are  pressed  upon,  the  reflexes  are  in- 
creased and  there  is  weakness  in  the  corre- 
sponding extremities.  There  may  be  palsy 
of  the  cranial  nerves,  difficulty  in  articula- 
tion, due  to  pressure  on  the  medulla,  and, 
occasionally,  epileptiform  convulsions.  If 
the  middle  peduncle  is  affected  by  an  irrita- 
tive lesion,  quite  characteristic  symptoms 
result.  "  Forced  movements"  occur — that 
is  to  say, .  the  body  is  involuntarily  rotated 
upon  its  long  axis,  and  the  patient  may 
have  an  irresistible  tendency  to  lie  on  one 
side.  There  are  no  symptoms  diagnostic 
of  disease  of  the  superior  and  inferior  pedun- 
cles. Disease  of  one  side  of  the  pons  may 
cause  symptoms  similar  to  those  of  cerebellar 
trouble. 

Medulla  Oblongata.  If  the  nuclei  in  the 
floor  of  the  fourth  ventricle  are  diseased, 
bulbar  palsy,  described  on  page  893,  results. 
It  must  be  remembered  that  bilateral  lesions 
in  the  lowest  part  of  each  ascending  frontal 
convolution  may  cause  symptoms  indistin- 
guishable from  true  bulbar  palsy. 

Spinal  Localization. 

The  localizing  symptoms  in  disease  or 
injury  of  the  cord  vary  with  the  level  at 
which  the  lesion  is  situated  and  with  the 
part  of  the  transverse  area  involved. 

A  total  transverse  lesion  causes,  of 
course,  total  paralysis,  with  anaesthesia,  of 
all  parts  below,  including  the  bladder  and 
rectum.  If  situated  above  the  lumbar  en- 
largement, the  knee-jerk  is  increased,  the 
legs  become  spastic,  and  ankle -clonus  ap- 
Diagram  showing  the  relations  ot   pears  on  account  of  secondarv  degeneration 

the  vertebral  bodies  and   spines  to    of    the    kteral    tracts>        jf    ^    h]mbar   eQ_ 


10 


12 


12 


0 


the  segments  of  the  cord  and  to    , 

the  exits  of  the  nerves.  (Gowers.)   largement    is    involved,    the    reflexes    are 


DISEASES  OF  THE  NERVOUS  SYSTEM.  853 

abolished  and  the  palsy  is  flaccid.  Much  finer  local  diagnosis  can  be 
made  bv  a  study  of  Fio-.  174,  and  the  table  of  the  functions  of  the 
different  segments  of  the  cord  which  I  quote  from  M.  Allen  Starr. 
It  is  important  to  remember  that  the  segments  of  the  cord  do  not  cor- 
respond to  the- vertebra  after  which  they  are  named. 

Unilateral  lesions  produce  palsy  on  the  same  side,  with  increased 
reflexes  and  rigidity,  and  on  the  opposite  side  anaesthesia,  reaching 
not  quite  up  to  the  seat  of  lesion.  There  may  be  some  palsy  on  the 
side  opposite  the  lesion  because  some  fibres  of  the  lateral  pyramidal 
tract  have  not  decussated.  If  the  lesion  is  situated  below  the  point 
of  decussation  of  the  sensory  fibres,  anaesthesia  will  be  upon  the  same 
side  as  the  palsy. 

Antero-lateral  White  Columns.  Disease  of  this  area  causes  loss  or 
diminution  of  voluntary  movement,  descending  lateral  degeneration, 
increased  reflexes,  and  rigidity  of  the  muscles.  We  find  this  condition 
in  primary  lateral  sclerosis.  If  the  motor  cells  in  the  anterior  horn 
are  also  degenerated,  wasting  is  added  to  the  other  symptoms,  and  as 
it  progresses  the  exaggeration  of  the  reflexes  and  the  rigidity  disap- 
pear, and  we  have  a  flaccid  palsy.  This  condition  of  palsy  with 
rigidity  in  some  muscles  and  palsy  with  wasting  in  others  is  found 
in  amyotrophic  lateral  sclerosis. 

Posterior  White  Columns.  If  the  postero-external  columns  are  affected, 
there  results  muscular  incoordination,  with,  in  some  cases,  loss  of 
power,  lancinating  pains,  abolished  knee-jerk,  and  impaired  sensation. 
Locomotor  ataxia  is  the  type  of  disease  in  this  region.  The  symptoms 
of  disease  of  the  poster -o -median  columns  are  unknown. 

Anterior  Horns.  The  large  cells  in  the  anterior  horns  are  the 
trophic  cells  of  the  nerves  proceeding  from  them.  If  they  become 
diseased,  therefore,  the  corresponding  muscles  waste  or  atrophy.  There 
is  also  palsy,  because  these  cells  are,  if  one  may  say  so,  a  way-station 
between  the  periphery  and  the  cortex;  and,  as  they  are  also  a  link  in 
the  reflex  arc,  the  muscle-reflexes  are  abolished.  The  reaction  of  de- 
generation, which  occurs  very  promptly,  is  the  most  important  symptom, 
for  it  indicates  positively  that  the  anterior  horns  are  affected,  unless 
the  peripheral  nerves  are  involved.  Muscular  atrophy  develops  rap- 
idly and  is  extreme.  There  may  be  slight  wasting  in  cerebral  palsy, 
but  it  is  simply  from  disuse,  and  reaction  of  degeneration  is  never  pres- 
ent. The  extent  of  the  palsy  and  wasting  depends  upon  the  extent  of 
cord  involved.     It  may  affect  one  or  several  or  all  four  extremities. 

Diseases  of  the  Cranial  Nerves.     Examination  of  the 
Functions  of  the  Cranial  Nerves. 

Olfactory  Nerve.  A  rhinoscopic  examination  should  always  be 
made  to  discover  whether  local  disease  exists,  since  this  may  destroy 
all  sense  of  smell.  Irritating  substances  must  not  be  used  in  examin- 
ing, since  they  stimulate  the  trifacial  nerve.  Cologne  water  or  acetic 
acid  may  be  employed.  Each  nostril  should  be  examined  separately. 
Disturbance  of  function  may  arise  from  a  lesion  anywhere  between  the 
periphery  and  the  cortical  origin. 


854 


SPECIAL  DIAGNOSIS. 


Segment. 


II.  and  III. 


IV.  c. 


V.  c. 


VI.  c. 


VII.  c. 


VIII.  c. 

I.  D. 


II.  to  XII. 

D. 


I.  L. 


II.  L. 


III.  L. 


IV.  L. 


V.  L. 


I.  to  II.  S. 


Muscles. 


Sterno-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Diaphragm. 

Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator  longus. 

Rhomboid. 

Supra-  and  infra-spinatus. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator  longus. 

Supinator  brevis. 

Rhomboid. 

Teres  minor. 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

Biceps. 

Brachialis  anticus. 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

Triceps. 

Extensors  of  wrist  and  fingers 

Pronators. 


Triceps  (long  head). 
Extensors  of  wrist  and  fingers 
Pronators  of  wrist. 
Flexors  of  wrist. 
Subscapular. 
Pectoralis  (costal  part). 
Latissimus  dorsi. 
Teres  major. 

Flexors  of  wrist  and  fingers. 
Intrinsic  muscles  of  hand. 

Extensors  of  thumb. 
Intrinsic  hand  muscles. 
Thenar  and  hypothenar  emi- 
nences. 

Muscles  of  back  and  abdomen 
Erectores  spinse. 


Ilio- psoas. 
Sartorius. 
Muscles  of  abdomen. 

Ilio-psoas.    Sartorius. 
Flexors  of  knee  (Remak). 
Quadriceps  femoris. 

Quadriceps  femoris. 
Inner  rotators  of  thigh. 
Abductors  of  thigh. 

Abductors  of  thigh. 
Adductors  of  thigh. 
Flexors  of  knee  (Ferrier). 
Tibialis  anticus. 

Outward  rotators  of  thigh. 
Flexors  of  knee  (Ferrier). 
Flexors  of  ankle. 
Extensors  of  toes. 

Flexors  of  ankle. 

Long  flexors  of  toes. 

Peronei. 

Intrinsic  muscles  of  foot. 

Perineal  muscles. 


Reflex. 


Hypochondrium  (?). 

Sudden  inspiration  produced 
by  sudden  pressure  beneath 
the  lower  border  of  ribs. 

Pupil.  4th  to  7th  cervical. 
Dilatation  of  the  pupil  pro- 
duced by  irritation  of  neck. 


Scapular. 

5th  cervical  to  1st  dorsal. 

Irritation  of  skin  over  the  sca- 
pula produces  contraction 
of  the  scapular  muscles. 

Supinator  longus. 

Tapping  its  tendon  in  wrist 
produces  flexion  of  forearm. 

Triceps. 

6th  to  7th  cervical. 

Tapping  elbow  tendon  pro- 
duces extension  of  forearm. 

Posterior  wrist. 

6th  to  8th  cervical. 

Tapping  tendons  causes  ex- 
tension of  hand. 

Anterior  wrist. 

Tapping  anterior  tendons 

causes  flexion  of  wrist. 
Palmar.    7th  cervical  to  1st 

dorsal. 
Stroking  palm  causes  closure 

of  fingers. 


Sensation. 


Epigastric.    4th  to  7th  dorsal. 

Tickling  mammary  region 
causes  retraction  of  the  epi- 
gastrium. 

Abdominal.  7th  to  11th  dorsal 

Stroking  side  of  abdomen 
causes  retraction  of  belly. 

Cremasteric.  1st  to  3d  lumbar 
Stroking  inner  thigh  causes 
retraction  of  scrotum. 

Patellar  tendon. 
Striking  tendon    causes   ex- 
tension of  leg. 


Gluteal. 

4th  to  5th  lumbar. 
Stroking  buttock  causes 
dimpling  in  fold  of  buttock 


Plantar. 

Tickling  sole  of  foot  causes 
flexion  of  toes  and  retrac- 
tion of  leg. 

Foot  reflex.  Achilles' tendon. 

Overextension  of  foot  causes 
rapid  flexion;  ankle-clonus. 

Bladder  and  rectal  centres. 


Back  of  head  to  vertex. 
Neck. 


Neck. 

Upper  shoulder. 

Outer  arm. 


Back  of  shoulder  and 

arm. 
Outer  side  of  arm  and 

forearm,  front   and 

back. 


Outer  side  of  forearm, 

front  and  back. 
Outer  half  of  hand. 


Inner  side  aud  back  of 
arm  and  forearm. 

Radial  half  of  the 
hand. 


Forearm    and    hand, 
inner  half. 

Forearm,  inner  half. 
Ulnar   distribution  to 
hand. 


Skin  of  chest  and 
abdomen,  in  bands 
running  around  and 
downward  corre- 
sponding to  spinal 
nerve. 

Upper  gluteal  region. 

Skin  over  groin  and 
front  of  scrotum. 


Outer  side  of  thigh. 


Front  and  inner  side 
of  thigh. 

Inner   side   of    thigh 

and  leg  to  ankle. 
Inner  side  of  foot. 


Back  of  thigh,  back  of 
leg,  and  outer  part 
of  foot. 


Back  of  thigh.     Leg 
and  foot,  outer  side. 
Skin  over  sacrum. 
Anus. 
Perineum.    Genitals. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  855 

Anosmia,  loss  of  the  sense  of  smell,  may  be  caused  by  acute  or 
chronic  nasal  catarrh;  abnormal  dryness  of  the  mucous  membrane, 
from  disease  of  the  trifacial;  traumatism  of  the  bulbs  or  nerves;  men- 
ingitis or  tumor  causing  pressure  upon  or  inflammation  of  the  bulbs 
or  nerve-trunks;  and,  finally,  lesions  of  the  olfactory  centre,  placed 
by  Ferrier  in  the  uncinate  gyrus.  It  is  frequently  met  with  in  hys- 
teria, and  is  sometimes  seen  in  workers  in  strong-smelling  substances. 

Parosmia,  subjective  sensation  of  smell,  is  found  among  the  insane 
and  in  cases  of  migraine,  tic  douloureux,  epilepsy,  hysteria,  and  tabes 
dorsalis.     Usually  the  odors  are  unpleasant. 

Hyperosmia,  increased  acuteness  of  smell,  occurs  in  hysteria.  It 
may  be  so  marked  as  to  enable  the  patient  to  recognize  persons  by  the 
sense  of  smell  alone. 

Optic  Nerve  and  Tract.  This  is  the  most  important  of  the 
cranial  nerves  in  relation  to  general  diseases,  especially  those  of  the 
nervous  system. 

Retinal  Lesions,  («)  Retinitis  sometimes  occurs  as  an  idiopathic 
affection,  but  more  frequently  it  is  found  in  association  with  Bright' s 
disease,  syphilis,  leukaemia,  and  severe  anaemia.  It  is  occasionally 
present  in  diabetes,  purpura,  and  chronic  lead-poisoning.  Whatever 
the  cause,  there  are  seen,  on  ophthalmoscopic  examination  of  the  retina, 
white  spots  and  patches  of  various  sizes  and  distribution,  due  for  the 
most  part  to  degenerative  processes,  and  usually  hemorrhages.  The 
latter  are  in  the  nerve-fibre  layer  and  often  follow  the  course  of 
bloodvessels.  Wh,en  recent  they  are  bright  red  in  color,  when  old, 
black. 

Albuminuric  retinitis  occurs  only  in  chronic  renal  disease.  It  is  most 
frequent  in  granular  kidney,  least  so  in  lardaceous  disease.  It  may  be 
present  when  there  is  little  or  no  albumin  iu  the  urine,  and  is  prac- 
tically never  coexistent  with  functional  albuminuria.  Its  presence 
proves  organic  renal  disease.  Gowers  distinguishes  four  types — the 
degenerative,  the  hemorrhagic,  the  inflammatory,  and  the  neuritic, 
according  as  white  spots  of  degeneration,  extravasations  of  blood, 
parenchymatous  retinal  inflammation,  or  inflammation  limited  to  the 
optic  nerve  predominates. 

(b)  Functional  blindness,  toxic  amaurosis,  occurs  quite  often  in  urae- 
mia, sometimes  in  acute  or  chronic  lead-poisoning,  and,  occasionally, 
from  quinine.  In  hysteria  there  may  be  blindness  in  one  or  both  eyes, 
but  more  often  there  is  only  a  marked  decrease  in  visual  acuity.  In 
this  condition  ophthalmoscopic  examination  reveals  nothing. 

(c)  Tobacco-amblyopia  is  gradual  in  onset  and  equal  in  both  eyes.  It 
is  characterized  by  defect  in  the  centre  of  the  field  of  vision,  a  central 
scotoma.  The  scotoma  is  relative,  not  absolute;  vision  is  dimmed, 
not  lost,  and  the  failure  is  greater  for  red  and  green  than  for  white. 
The  eye-grounds  may  be  normal,  but  if  tobacco  is  persistently  used, 
atrophy  of  the  disk  may  result. 

(c/)  Nyctalopia,  or  night-blindness,  is  the  condition  in  which  objects 
are  clearly  seen  in  a  bright  light,  but  are  invisible  in  the  shade  or  in 
twilight.  It  is  a  symptom  of  commencing  optic  atrophy,  especially 
syphilitic.     In  hemeralopia,  the  reverse  condition  exists. 


856  SPECIAL  DIAGNOSIS. 

(e)  Retinal  hyperesthesia  occurs  in  hysteria  and  acute  meningitis, 
and,  rarely,  in  retinitis. 

Optic  Neuritis.  (Choked  disk,  papillitis.)  The  disk  is  swollen 
and  hypersernic,  its  edges  are  blurred,  and  a  striated  and  grayish  hazi- 
ness spreads  over  its  face  and  out  upon  the  retina.  If  the  swelling- 
has  been  great,  complete  atrophy  follows  its  subsidence.  In  the  early 
stages  there  is  no  disturbance  of  vision,  and  even  when  the  inflamma- 
tion is  quite  severe  the  sight  may  continue  quite  good  for  some  time. 

Papillitis  is  rarely  idiopathic.  It  occurs  sometimes  in  anaemia  and 
lead-poisoning,  not  uncommonly  in  Bright' s  disease  as  a  neuro-retinitis, 
and  commonly  in  meningitis  and  tumor  of  the  brain.  Its  frequent 
presence  in  the  last  disease  renders  it  of  great  diagnostic  value.  It 
must  be  remembered,  however,  that  the  presence  of  papillitis  gives  no 
information  as  to  the  locality  or  pathological  nature  of  a  brain-tumor. 

Optic  Atrophy  may  result  from  alcohol,  lead-poisoning,  diabetes, 
and  the  specific  fevers.  Many  cases  are  associated  with  spinal-cord 
diseases,  particularly  locomotor  ataxia.  Secondary  atrophy  is  most 
commonly  the  result  of  papillitis,  but  it  may  result  from  cortical  brain 
disease  or  pressure  on  the  chiasma  or  nerves. 

The  disk  is  pale,  bluish,  or  grayish,  and  its  outlines  are  distinctly 
marked.  Visual  acuity  is  lessened,  color-perception  is  altered,  and  the 
field  is  contracted.  There  is  no  pain  and  seldom  photophobia.  Prog- 
nosis is  usually  bad. 

Diseases  op  the  Optic  Chiasm  and  Tract.  There  is  a  semi- 
decussation of  the  optic  nerves  at  the  chiasm.  The  fibres  from  the 
outer  half  of  each  retina  pass  to  the  centre  on  the  same  side,  while 
those  on  the  inner  half  cross  and  pass  to  the  centre  of  the  opposite 
side.  Remembering  this,  the  symptoms  resulting  from  lesion  of  the 
chiasm  or  tract  are  easily  understood. 

Unilateral  Lesions  of  the  Tract.  If  the  lesion  is  situated  at,  say,  b, 
Fig.  176,  there  will  result  loss  of  function  of  the  temporal  half  of  the 
right  and  nasal  half  of  the  left  retina,  so  that  the  patient  sees  objects 
only  on  the  right  side.  This  condition  is  called  lateral  or  homonymous 
hemianopia. 

Fig.  175. 


L   J  ^    R 

Diagram  showing  the  course  of  the  optic  fibres  in  the  chiasm.    (Hirt.) 

Lesion  of  the  Chiasma.  If  the  central  portion  of  the  chiasma,  made 
up  of  decussating  fibres  from  the  nasal  side  of  the  retina?,  be  alone 
involved,  there  will  result  loss  of  vision  in  the  outer  half  of  each  field 
— temporal  hemianopia.  (The  picture  projected  on  the  retina  is,  of 
course,  reversed.)     If  the  lesion  involves  not  only  the  central  portion, 


DISEASES  OF  THE  NEB  VO  US  S YSTEM.  857 

but  also  the  direct  fibres  on  one  side,  there  result  total  blindness  in 
one  eye  and  temporal  hemianopia  in  the  other.  Finally,  if  the  entire 
chiasm  is  involved,  total  blindness  results.  If  the  lesion  affects  the 
outer  part  of  the  chiasma,  involving  the  fibres  going  to  the  temporal 
halves  of  the  retina?,  blindness  results  in  the  nasal  field — nasal  hemi- 
anopia. 

Lesion  of  the  Tract  and  Centres.  The  optic  tract  after  crossing  the 
cms  to  the  hinder  part  of  the  optic  thalamus  divides  into  two  branches, 
one  going  to  the  thalamus  and  external  geniculate  bodies  and  to  the 
anterior  quadrigeminal  bodies,  from  which  fibres  pass  into  the  hinder 
part  of  the  internal  capsule,  and,  entering  the  occipital  lobe,  form  the 
fibres  of  the  optic  radiation  terminating  in  the  cuneus,  the  perceptive 
visual  centre,  while  the  fibres  of  the  other  branch  pass  to  the  internal 
geniculate  bodies  and  the  posterior  quadrigeminal  bodies.  It  is  held 
by  some  physiologists  that  the  visual  centre  is  not  confined  to  the  occip- 
ital lobe,  but  includes  the  occipito-angular  region. 

A  lesion  anywhere  in  the  tract  from  the  chiasma  to  the  cortex  will 
of  necessity  produce  lateral  hemianopia.  To  sum  up,  the  lesion  may 
be  in  the  tract  itself,  in  the  region  of  the  thalamus,  in  the  corpora 
quadrigemina,  in  the  fibres  passing  from  the  latter  to  the  occipital  lobe, 
either  in  the  hinder  part  of  the  internal  capsule,  or  in  the  white  fibres 
of  the  optic  radiation,  or  finally  in  the  cuneus.  Bilateral  disease  in  any 
of  these  situations  will,  of  course,  produce  blindness  in  both  eyes. 

Can  we  locate  more  definitely  the  seat  of  the  lesion  ?  In  some 
cases,  yes.  If  it  is  in  the  posterior  part  of  the  internal  capsule,  hemi- 
ansesthesia  of  the  opposite  side,  and,  if  it  extends  far  enough  forward 
in  the  capsule,  hemiplegia,  will  be  associated  with  the  hemianopia. 
Again,  it  has  been  found  by  Wernicke  that,  if  a  beam  of  light  is 
thrown  laterally  into  a  hemiaoopic  eye,  on  the  blind  side,  the  pupil 
will  not  contract  in  some  cases.  Now  the  light-reflex  of  the  pupil 
depends  upon  the  integrity  of  the  retina,  of  the  fibres  of  the  nerve 
and  tract,  and  of  the  nerve-centre  in  the  geniculate  bodies ;  the  latter 
receives  the  impression  and  transmits  it  to  the  third  nerve,  along  which 
the  motor  impulse  passes  to  the  iris.  If  then  we  find,  on  examining 
the  pupil  by  the  method  detailed  below,  that  there  is  pupillary  inac- 
tion on  the  side  corresponding  to  the  blind  half  of  the  retina,  we  are 
justified  in  saying  that  the  lesion  is  very  probably  in  the  geniculate 
bodies  or  anterior  to  them,  while,  if  both  sides  of  the  pupil  respond, 
it  is  posterior.  The  test  is  a  delicate  one,  not  easy  to  make,  and, 
according  to  recent  research,  not  always  reliable.  Seguin  uses  the  fol- 
lowing method  : 

"  The  patient  being  in  a  dark  room,  with  the  lamp  or  gaslight 
behind  his  head  in  the  usual  position,  I  bid  him  look  over  to  the  other 
side  of  the  room,  so  as  to  exclude  the  accommodative  iris-movements 
(which  are  not  necessarily  associated  with  the  reflex).  Then  I  throw 
a  faint  light  from  a  plane  mirror  or  from  a  large  concave  mirror  held 
well  out  of  focus  upon  the  eye,  and  note  the  side  of  the  pupil.  With 
my  other  hand  I  now  throw  a  beam  of  light,  focussed  from  the  lamp 
by  an  ophthalmoscopic  mirror,  directly  into  the  optical  centre  of  the 
eye  ;  then  laterally  in  various  positions  and  also  from  above  and  below 


858 


SPECIAL  DIAGNOSIS. 


the  equator  of  the  eye,  noting  the  reaction  at  all  angles  of  incidence  of 
the  ray  of  light." 

Fig.  176. 

LEFT  VISUAL  FIELD.    RIGHT  VISUAL  FIELD. 

Fixation  Point.  Fixation  Poi/if. 


L.  Genicu/ate  .Body 
L  Jnt  Capsule 


R.  Int. Capsule 


Ccfaitat Cortex- 


R.  Occip 


ipitd 


The  optic  and  visual  tracts.  N,  lesion  causing  nasal  hemianopia;  T,  lesion  causing  temporal 
hemianopia  ;  H,  lesion  causing  bilateral  heteronymous  hemianopia ;  B,  lesion  of  tract  causing 
homonymous  hemianopia.    (Starr.) 

Hemianopia  also  occurs  without  discoverable  organic  lesion,  as,  for 
example,  in  hysteria  and  migraine.    Lesion  of  the  angular  gyrus  seems 


DISEASES  OF  THE  NERVOUS  SYSTEM.  859 

to  produce  crossed  amblyopia — that  is,  dimness  of  vision  in  the  eye 
opposite,  with  contraction  of  the  visual  field,  more  often  than  hemi- 
enopia.  Lesions  in  this  region  are  also  associated  with  mind-blindness — 
the  condition  in  which,  while  the  patient  sees,  he  does  not  recognize 
objects. 

The  Oculomotor  Nerve.  Motor  Nerves  of  the  Eyeball.  The 
third  nerve  supplies  the  levator  palpebral  superioris,  the  superior  rectus, 
the  internal  and  inferior  rectus,  the  inferior  oblique,  the  ciliary  muscle, 
and  the  constrictor  of  the  iris.  Lesion  of  this  nerve  may  produce 
either  spasm  or  palsy.  It  may  be  affected  either  in  its  nucleus  or  along 
its  course.  If  the  nucleus  is  affected,  there  is  usually  associated  disease 
of  the  nuclei  of  the  other  ocular  nerves.  If  the  nerve  is  affected,  it 
may  be  from  inflammation  or  involvement  by  meningitis,  tumors,  or 
aneurism.  Complete  paralysis  causes  the  following  symptoms :  The 
eye  can  be  moved  outward  and  a  little  downward  and  inward.  There 
is  divergent  strabismus,  causing  diplopia,  owing  to  the  unopposed 
action  of  the  external  recti;  ptosis  or  drooping  of  the  upper  lid,  due  to 
the  paralysis  of  the  levator  palpebra?;  the  pupil,  while  of  moderate 
size,  does  not  contract  to  light,  and  power  of  accommodation  is  lost. 
The  eyeball  protrudes  slightly  on  account  of  the  palsy  of  the  three 
recti.  In  many  cases  only  one  or  more  branches  are  affected.  Thus 
we  may  have  only  palsy  of  the  levator  palpebral  and  superior  rectus, 
or  of  the  ciliary  muscle  and  iris. 

The  remarkable  condition  in  which,  at  irregular  intervals  throughout 
life,  there  recurs  a  complete  oculomotor  palsy  need  only  be  mentioned. 
In  paralysis  of  the  ciliary  muscle  (cycloplegia)  there  is  loss  of  accom- 
modation, so  that,  while  distant  vision  is  perfect,  near-by  objects 
cannot  be  clearly  seen  without  the  aid  of  convex  glasses.  The  con- 
dition is  frequently  met  with  in  diphtheritic  palsy  and  in  tabes. 

The  iris  has  three  actions  (Gowers):  1.  Reflex  contraction  of  the 
sphincter,  or  exposure  to  light.  2.  Reflex  dilatation  by  the  radiating 
fibres,  on  stimulation  of  a  cutaneous  nerve.  3.  Contraction  on  accom- 
modation, usually,  but  not  necessarily,  associated  with  convergence. 
There  are,  therefore,  three  forms  of  paralysis  of  the  iris  (iridoplegia) : 

1.  Accommodation,  in  which,  during  accommodation,  the  pupil  does 
not  diminish  in  size.  To  test  this  condition,  it  is  simply  necessary 
to  make  the  patient  look  at  a  distant  object  and  then  at  a  near  one, 
both  being  in  the  same  line  of  vision,  so  as  to  avoid  any  change  in  the 
amount  of  light  entering  the  eye. 

2.  Reflex,  in  which  the  pupil  does  not  contract  when  exposed  to  light. 
Each  eye  must  be  examined  separately,  keeping  the  other  covered,  since 
light  entering  one  eye  acts  on  both  pupils.  It  is  best  tested  by  having 
the  patient  look  at  a  distant  object  in  a  darkened  room,  and  then  bring- 
ing a  light  suddenly  in  front  of  the  eye.  If  the  light-reflex  is  lost 
and  the  accommodation-reflex  is  retained,  it  is  known  as  the  Argyll- 
Robertson  pupil. 

3.  Loss  of  Skin-reflex.  Pinching  or  pricking  the  skin,  say  of  the 
back  of  the  neck,  will  in  most  healthy  persons  produce  dilatation  of 
the  pupil,  the  afferent  impulse  being  sent  along  the  cervical  sympa- 
thetic. 


860  SPECIAL  DIAGNOSIS. 

In  iridoplegia  the  pupils  are  usually  small,  but  they  may  be  of 
medium  size.  Nystagmus  is  a  spasmodic  condition  of  the  muscles  of 
the  eye,  producing  rapid  oscillations  of  the  ball,  usually  horizontal, 
sometimes  rotary,  and  rarely  vertical.  It  is  of  great  value  as  a  symp- 
tom. It  is  found  in  many  brain-lesions,  especially  those  of  the  resti- 
forni  bodies  or  the  vermiform  process  of  the  cerebellum,  in  albinism, 
and  often  in  miners. 

Blepharospasm,  spasm  of  the  orbicularis  palpebrarum,  may  cause 
only  a  twitching  of  the  eyelids,  or  it  may  be  so  severe  as  forcibly  to 
press  the  eyelids  together,  so  that  the  patient  cannot  open  them. 

Ptosis  is  of  sufficient  importance  to  require  a  more  detailed  descrip- 
tion. It  may  be  congenital,  in  which  case  it  is  apt  to  be  bilateral  and 
partial,  due  to  lesion  of  the  third  nerve  or  its  nucleus,  or  associated 
with  cerebral  disease  without  the  other  branches  of  the  third  nerve 
being  affected;  or  hysterical.  When  the  cervical  sympathetic  is  par- 
alyzed the  upper  lid  on  the  same  side  is  a  little  lower  than  the  other, 
due  to  the  palsy  of  the  fibres  of  Muller.  The  movements  of  the  lid 
are,  however,  unimpaired,  and  other  symptoms  of  sympathetic  palsy, 
such  as  contraction  of  the  pupil,  dilatation  of  the  vessels  of  the  sur- 
face, and  altered  secretion  of  sweat,,  are  always  present.  Very  rarely 
irritation  of  the  fifth  nerve  will  cause  transient  ptosis.  Occasionally, 
especially  in  sickly  women,  there  is  a  condition  called  morning -ptosis, 
in  which  for  s  jme  minutes  after  waking  it  is  impossible  for  the  patient 
to  open  the  eyes. 

The  Trochlear  or  Pathetic  Nerve.  Fourth  Nerve.  The 
superior  oblique  muscle  is  supplied  by  the  fourth  nerve.  When  this 
becomes  paralyzed  the  downward  and  inward  movements  are  defective, 
causing  diplopia  on  looking  down. 

The  Trigeminus.  The  Fifth  Nerve  is  the  great  sensory  nerve  of 
the  face.  It  supplies  the  entire  side  of  the  face,  the  conjunctiva,  the 
mucous  membrane  of  the  lip,  gums,  tongue,  hard  and  soft  palate,  and 
of  the  nose.  It  supplies  the  anterior  two-thirds  of  the  tongue  with  the 
nerves  of  taste.  Its  motor  division  supplies  the  muscles  of  the  lower 
jaw,  temporal,  masseter,  pterygoid,  the  mylo-hyoid,  and  the  posterior 
belly  of  the  digastric. 

Paralysis  is  caused  by  (1)  hemorrhage  or  other  lesion  in  the  pons; 
(2)  tumor  at  the  base  of  the  brain,  meningitis,  or  caries ;  (3)  the 
branches  may  be  affected  in  their  course — the  first  by  tumor  pressing 
on  the  cavernous  sinus,  the  second  and  third  by  tumor  invading 
the  spheno-maxillary  fossa;  (4)  primary  neuritis,  which  is  very  rare. 
Secondary  neuritis  by  extension  is,  of  course,  common. 

Symptoms.  Sensory.  Anaesthesia  is  present  over  the  entire  distribu- 
tion or  in  one  branch,  according  as  the  entire  trunk  or  only  one  branch 
is  affected.  There  is  also  loss  of  taste  in  the  anterior  two-thirds  of 
the  tongue,  and  of  smell  in  the  nostril  corresponding  to  the  affected 
nerve.  The  salivary,  lacrymal,  and  buccal  secretions  may  be  lessened. 
If  the  Gasserian  ganglion  is  affected,  the  eye  becomes  inflamed  and  the 
cornea  becomes  cloudy  and  may  ulcerate.  Herpes  sometimes  develops. 
The  anaesthesia  may  be  preceded  by  darting,  burning  pain. 

Motor.     There  is  inability  to  masticate  on  the  affected  side.     If  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  861 

pterygoid  be  affected,  the  jaw,  when  depressed,  deviates  toward  the 
palsied  side. 

Spasm  of  the  muscles  of  mastication  produces  trismus.  It  may  be 
clonic  or  tonic,  and  may  occur  in  general  convulsions,  or — but  this  is 
rare — as  an  isolated  affection.  In  the  tonic  form  the  jaws  cannot  be 
opened.     Clonic  spasm  is  exemplified  in  chattering  teeth. 

Gustatory.  While,  as  stated  above,  there  is  likely  to  be  loss  of  taste 
in  the  anterior  two-thirds  of  the  tongue,  this  is  not  always  so.  The 
fibres  that  supply  this  region  may  escape,  or  the  lesion  may  be  situated 
within  the  pons  where  they  are  separated  from  those  of  sensation. 

Neuralgia.  (Trifacial  neuralgia,  tic  douloureux,  prosopalgia. )  The 
trifacial  is  more  frequently  the  seat  of  neuralgia  than  any  other  nerve. 
All  the  branches  are  rarely  affected  at  the  same  time.  The  ophthalmic 
is  most  often  affected,  producing  the  so-called  brow-ague,  supraorbital 
neuralgia.  The  pain  radiates  from  the  supraorbital  notch  over  the 
anterior  half  of  the  head  and  may  extend  to  the  side  of  the  nose.  The 
supraorbital  notch,  or  the  nerve  just  above  it,  is  painful  on  pressure. 
In  ocular  neuralgia  there  is  pain  confined  to  the  ball ;  both  eyes  may 
be  involved.  In  infraorbital  neuralgia  the  second  branch  is  affected 
and  the  pain  extends  from  the  orbit  to  the  mouth  and  over  the  cheek. 
There  are  points  painful  on  pressure  over  the  infraorbital  foramen, 
over  the  malar  bone,  and  above  the  gum  of  the  upper  jaw. 

If  the  third  division  is  affected,  there  is  pain  in  the  parietal  region, 
the  temple,  the  lower  jaw,  and  the  tongue.  There  are  tender  points 
at  the  inferior  dental  foramen,  at  the  posterior  part  of  the  temporal 
region,  and  over  the  parietal  eminence. 

The  pain  is  always  severe  and  its  description  varies  with  the  powers 
of  the  patient :  burning,  tearing,  boring,  etc.  When  sudden  and  severe, 
the  reflex  muscular  spasm,  the  tie  convulsif,  occurs. 

The  Motor  Oculi  Externus  or  Abducens.  Sixth  Nerve.  The 
external  rectus  muscle  is  supplied  by  it.  Palsy  of  it  produces  defect 
of  outward  movement  of  the  ball  and  consequent  convergent  strabis- 
mus.    Diplopia  occurs  on  looking  to  the  paralyzed  side. 

Acute  Ophthalmoplegia.  Acute  Nuclear  Palsy.  Sudden  paralysis 
of  all  the  ocular  muscles  sometimes  occurs  from  hemorrhage  in  the 
region  of  the  nuclei.  The  apoplexy  is  usually  fatal.  It  is  not  known 
whether  multiple  neuritis  ever  affects  the  ocular  nerves.  If  it  does, 
the  resulting  palsy  would  simulate  nuclear  disease. 

Chronic  ophthalmoplegia  may  affect  either  the  external  or  internal  eye- 
muscles.  In  the  first  the  levator  muscle  and  the  superior  recti  are  first 
affected,  later  the  others,  so  that  finally  the  balls  are  immovable  and 
the  eyelids  droop.  The  condition  may  persist  for  years.  It  is  often 
associated  with  general  paralysis  and  tabes  dorsalis.  In  the  second 
there  is  no  pupillary  reflex  either  to  light  or  with  accommodation. 
The  two  forms  may  occur  together. 

Spasm  of  the  Ocular  Muscles.  They  are  grouped  by  Gowers  into 
five  classes : 

1.  Associated  Spasm  from  Central  Disease.  In  a  paralyzing  lesion 
of  one  hemisphere  the  eyes  deviate  toward  this  side  because  of  the 
unopposed  influence  of  the  opposite  hemisphere.     An  irritative  lesion 


862  SPECIAL  DIAGNOSIS. 

of  one  hemisphere  causes  conjugate  deviation  due  to  spasm  toward  the 
opposite  side.     It  occurs  at  the  onset  of  unilateral  convulsions. 

2.  Irregular  Spasm  from  Brain  Disease.  In  irritating  disease  of 
the  base  of  the  brain,  especially  in  meningitis,  there  may  be  spasm  of 
one  or  more  ocular  muscles. 

3.  Chronic  spasm  in  individual  muscles  is  very  rare  except  in  cases 
of  secondary  deviation. 

4.  Hysterical  Spasm.  In  fits  of  hysteria  the  eyes  are  usually  directed 
upward  and  to  one  side,  often  concealing  the  cornea  entirely,  or  there 
may  be  marked  convergence,  but  never  divergence.  Convergence  may 
persist  during  the  interval. 

5.  Paroxysmal  spasm  occurs  in  convulsive  attacks.  Cases  are  occa- 
sionally met  with  in  which  only  one  muscle  is  affected,  there  being  at 
the  same  time  momentary  loss  of  consciousness. 

The  Facial  Nerve.  The  Seventh.  Paralysis  may  result  fioni 
lesion  of  the  cortex,  of  the  nucleus,  or  of  the  trunk.  The  cerebral 
form,  that  due  to  disease  above  the  nucleus,  is  easily  distinguished 
from  the  peripheral,  Bell's  palsy,  by  the  persistence  of  normal  elec- 
trical reactions  in  muscles  and  nerves,  and  by  the  non-involvement  of 
the  upper  branches,  so  that  the  orbicularis  palpebrarum  and  frontalis 
are  usually  but  not  invariably  spared.  Again,  voluntary  movements 
are  more  impaired  than  emotional  ones.  Besides,  supranuclear  disease 
(usually)  causes,  not  palsy  of  the  face  alone,  but  also  hemiplegia. 

Nuclear  palsy  rarely  occurs  alone,  but  is  seen  sometimes  in  tumors, 
chronic  softening,  and  hemorrhage.  In  anterior  poliomyelitis  and 
diphtheria  the  nucleus  may  be  affected.  The  condition  is  distinguished 
from  disease  of  the  trunk  by  being  purely  motor  and  being  usually 
associated  with  involvement  of  other  motor  nerves. 

In  the  peripheral  form,  Bell's  palsy,  all  branches  of  the  nerve  are 
involved,  excepting  in  traumatism  which  affects  only  certain  branches. 
The  face  on  the  affected  side  is  motionless,  the  skin  is  smooth,  the  eye 
cannot  be  closed,  and  the  lower  lid  droops.  The  angle  of  the  mouth 
droops  and  the  lips  on  the  affected  side  cannot  be  closed.  On  move- 
ment the  face  is  strongly  drawn  to  the  sound  side.  The  patient  cannot 
whistle,  and  he  may  have  difficulty  in  pronouncing  the  labials.  Food 
collects  between  the  teeth  and  cheeks.  The  tongue  when  protruded 
appears  to  deviate  to  the  injured  side  on  account  of  the  facial  deform- 
ity. In  most  cases  the  uvula  does  not  deviate.  All  reflex  move- 
ments are  lost.  There  is  no  change  in  the  electrical  reactions  in  slight 
cases.  In  severe  ones  degeneration- reaction  is  found.  If  the  lesion 
is  situated  between  the  geniculate  ganglion  and  the  origin  of  the  chorda 
tympani,  there  is  loss  of  the  sense  of  taste  in  the  anterior  part  of  the 
tongue,  on  the  affected  side,  and  diminished  salivary  secretion.  Hear- 
ing may  be  impaired,  usually  on  account  of  previous  ear  disease,  but 
is  sometimes  abnormally  acute  because  of  the  paralysis  of  the  stape- 
dius muscle.  In  old  cases  there  occurs  a  secondary  contraction  of  the 
muscles  on  the  affected  side,  which  draws  the  face  to  that  side,  increases 
wrinkling,  and,  while  at  rest,  makes  the  diseased  side  appear  the  healthy 
one. 

Double  facial  palsy  is  very  rare,  but  may  be  caused  by  lesions  at  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  863 

base,  in  the  pons,  by  disease  in  both  ears,  and  possibly  by  disease  of  the 
nuclei  or  double  cortical  lesions. 

Spasm  may  involve  a  few  or  all  of  the  muscles  and  may  be  bilat- 
eral. If  the  muscles  around  the  eye  are  affected,  it  is  called  blepharo- 
spasm. More  often  there  is  twitching  of  all  the  muscles  of  the  side  of 
the  face  and  partial  closure  of  the  eye — tic  convulsif. 

The  Auditory  Nerve.  The  Eighth.  Hearing  is  tested  by  the 
watch  or  a  tuning-fork.  Normally  the  instrument  should  be  heard 
at  an  equal  distance  from  either  ear.  If  both  sides  are  equally  affected, 
the  hearing  of  the  patient  must  be  compared  with  that  of  a  healthy 
person.  In  order  to  determine  whether  the  deafness  is  neurotic  or  due 
to  obstructive  disease,  we  test  the  sharpness  of  hearing  through  bone- 
conduction  (Rinne's  test).  If  the  cause  is  middle-ear  disease,  impacted 
cerumen,  or  obstruction  of  the  Eustachian  tube,  a  vibrating  tuning- 
fork  placed  upon  the  vertex  will  be  heard  much  more  intensely  on  the 
deaf  side.  In  certain  middle-ear  diseases,  however,  as,  for  example, 
ankylosis  of  the  bones,  this  does  not  hold  true. 

Hyperesthesia  of  the  Auditory  Nerve.  Very  rarely  in  certain  cases 
of  facial  paralysis,  and  not  seldom  in  hysteria,  there  is  abnormal  acute- 
ness  of  hearing  (oxyacoia).  In  some  individuals  suffering  from  hemi- 
crania  or  tic  douloureux,  and  in  meningitis,  the  hearing  of  certain 
sounds — for  example,  high  musical  notes  and  whistling — is  accompanied 
by  pain.  Nervous  patients  often  complain  of  subjective  noises,- buzzing, 
roaring,  hissing,  and  singing — the  so-called  tinnitus  aurium. 

Paralysis  of  the  Auditory  Nerve.  No  case  of  absolute  unilateral 
deafness,  due  to  a  focal  lesion  in  a  hemisphere,  has  as  yet  been  observed. 
Deafness  from  disease  of  the  auditory  nucleus  is  very  rare.  That  due 
to  disease  of  the  peripheral  nerve  is  much  more  common.  We  may 
have  a  rheumatic  auditory  paralysis  similar  to  that  of  the  facial  nerve, 
or  the  deafness  may  be  due  to  pressure  from  a  tumor  or  inflammatory 
exudate  at  the  base  of  the  brain,  or  disease  of  the  mastoid  process  of 
the  temporal  bone.  The  localization  of  the  lesion  is  often  extremely 
difficult.  The  only  positive  point  is,  that  labyrinthine  disease  is  apt 
to  be  accompanied  by  vertigo,  while  in  disease  of  the  nerve-trunk 
vertigo  is  absent.  Deafness  due  to  occupation  is  worthy  of  mention. 
It  is  not  uncommon  in  blacksmiths,  boilermakers,  locomotive  engi- 
neers, and  firemen.  In  some  instances  the  patients  can  hear  better  in 
the  noise  incident  to  their  work  than  when  the  surroundings  are  abso- 
lutely quiet. 

Meniere's  Disease.  Aural  Vertigo.  We  may  define  vertigo  as  a 
subjective  feeliug  of  motion  referred  by  the  patient  either  to  his  own 
body  or  to  surrounding  objects,  with  loss  of  equilibrium  and  without 
unconsciousness. 

In  this  disease,  first  described  by  P.  Meniere  in  1861,  there  is  par- 
oxysmal vertigo,  sometimes  so  sudden  and  intense  as  to  throw  the 
patient  to  the  ground;  tinnitus  auriitm,  nausea,  pallor,  clammy  sweat, 
and  vomiting.  The  severity  of  the  attacks  varies  greatly.  There 
may  be  momentary  unconsciousness.  There  is  sometimes  jerking  of 
the  eyeballs,  nystagmus,  or  diplopia.  The  disease  is  paroxysmal  in 
character,  but  slight  vertigo  and  tinnitus  are  apt  to  persist  between  the 


864  SPECIAL  DIAGNOSIS. 

attacks.  Some  deafness  is  present.  The  attacks  may  vary  in  fre- 
quency from  several  in  a  day  to  only  one  in  several  months. 

Paralyzing  Vertigo.  Gerlier  describes  a  remarkable  form  of  parox- 
ysmal vertigo  accompanied  by  weakness,  paresis  in  the  extremities, 
drooping  of  the  eyelids,  marked  lassitude  and  depression  without 
unconsciousness.  It  occurs  only  in  men  and  is  epidemic  in  the  Canton 
of  Geneva. 

The  Glossopharyngeal  Nerve.  The  NintJi.  This  nerve  sup- 
plies the  posterior  third  of  the  tongue  with  nerves  of  taste.  It  sends 
motor  branches  to  the  stylo-pharyngeus  and  the  middle  constrictor  of 
the  pharynx,  and  branches  of  common  sensation  to  the  upper  part  of 
the  pharynx.  To  test  the  sense  of  taste,  the  eyes  should  be  closed, 
the  tongue  protruded,  and  small  quantities  of  bitter,  sweet,  sour,  and 
salty  substances  applied  to  various  parts.  The  sensation  should  be 
perceived  before  the  patient  withdraws  the  tongue. 

We  know  but  little  about  central  diseases  of  this  nerve.  The  situ- 
ation of  its  cortical  centre  is  unknown.  A  central  paralysis  of  taste 
manifesting  itself  only  on  the  posterior  third  of  the  tongue  has  never 
been  observed.  Peripheral  loss  of  taste  (ageusia)  may  be  caused  by 
affections  of  the  mucous  membrane,  and  is  often  met  with  in  fevers 
and  in  the  coated  tongue  of  dyspepsia.  Perversion  of  taste  (parageu- 
sia) is  found  in  hysteria  and  insanity. 

The  Pneumogastrlc  Nerve.  The  Tenth.  This  nerve  supplies 
the  pharynx,  larynx,  lungs,  heart,  oesophagus,  and  stomach.  It  may 
be  compressed  by  tumors  or  inflammatory  exudates  It  has  been  tied 
in  ligating  the  carotid  and  cut  in  removing  tumors  from  the  neck. 
Its  nucleus  may  degenerate,  and  the  nerve  may  be  the  seat  of  the 
neuritis. 

Pharyngeal  Branches.  These,  with  branches  from  the  glosso- 
pharyngeal, supply  the  muscles  and  mucosa  of  the  pharynx.  In 
paralysis  either  from  nuclear  or  peripheral  disease,  there  is  difficulty 
in  swallowing,  and  the  food  does  not  pass  into  the  oesophagus,  but 
into  the  larynx  and  posterior  nares.      Spasm  is  always  functioual. 

Laryngeal  Branches.  The  superior  laryngeal  nerve  supplies  the 
mucosa  above  the  vocal  cords  and  the  crico-thyroid  muscle.  The 
recurrent  laryngeal  supplies  the  mucosa  below  the  cords  and  all  the 
muscles  of  the  larynx  except  the  crico-thyroid  and  the  epiglottidean. 
All  the  motor  branches  arise  from  the  spinal  accessory. 

Bilateral  Abductor  Paralysis.  If  the  posterior  crico-arytenoids  are 
involved,  the  glottis  is  not  opened  during  inspiration;  the  cords  are 
close  together,  so  that  there  is  stridor.  Phonation  is  unimpaired.  The 
affection  occurs  in  tabes,  bulbar  paralysis,  and  hysteria. 

Unilateral  Abductor  Paralysis.  Pressure  from  an  aneurism  is  the 
most  common  cause.  The  cord  on  the  affected  side  does  not  move  on 
inspiration.     The  voice  is  hoarse,  and,  rarely,  there  is  dyspnoea. 

Adductor  Paralysis.  There  is  palsy  of  the  lateral  crico-arytenoid 
and  arytenoid  muscles.  The  cords  cannot  be  brought  together  when 
phonation  is  attempted. 

The  following  table  from  Gowers  shows  the  different  conditions: 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


865 


Symptoms. 


No  voice  ;  no  cough  ;  stridor  only 
on  deep  inspiration. 

Voice  low-pitched  and  hoarse  ;  no 
cough ;  stridor  absent  or  slight 
on  deep  breathing. 


Voice  little  changed ;  cough  nor- 
mal ;  inspiration  difficult  and 
long,  with  loud  stridor. 


Symptoms     inconclusive ;     little 
affection  of  voice  or  cough. 


No  voice  ;  perfect  cough  ;  no  stri- 
dor or  dyspncea. 


Signs. 


Lesion. 


Total  bilateral  palsy. 


Both  cords  moderately  abducted 
and  motionless. 

One    cord   moderately  abducted  i  Total  unilateral  palsy. 
and  motionless,  the  other  mov- 
ing freely,  and  even  beyond  the 
middle  line  in  phonation. 


Both  cords  near  together,  and 
during  inspiration  not  separ- 
ated, but  even  drawn  nearer 
together. 

One  cord  near  the  middle  line  not 
moving  during  inspiration,  the 
other  normal. 

Cords  normal  in  position,  and 
moving  normally  in  respiration, 
but  not  brought  together  on  an 
attempt  at  phonation. 


Total  abductor  palsy. 


Unilateral  abductor  palsy. 


Adductor  palsy. 


Laryngeal  Spasm.  The  adductor  muscles  are  affected.  Under  the 
name  of  laryngismus  stridulus  it  is  frequently  met  with  in  children. 
It  is  the  cause  of  the  laryngeal  crisis  in  tabes.  There  is  no  cough  nor 
hoarseness,  but  respiration  ceases,  the  face  becomes  congested,  there  is 
a  struggle  for  breath,  and,  as  the  spasm  relaxes,  there  is  deep  inspira- 
tion, with  a  loud,  crowing  sound. 

Cardiac  Branches.  These  control  the  heart's  action.  Irritation 
may  produce  slowiug  of  the  pulse.  In  the  case  of  Czermak  it  was 
possible  to  stop  the  heart  for  a  few  beats  by  pressing  on  a  small  tumor 
in  the  neck.  If  the  nerve  be  palsied,  there  may  be  increase  in  the  fre- 
quency of  the  pulse.  Normally  the  heart  acts  without  our  being  aware 
of  its  beating. 

Pulmonary  Branches.  The  motor  branches  supply  the  bronchial 
muscles.     Asthma  may  be  a  neurosis  of  this  nerve. 

Gastric  and  Oesophageal  Branches.  These  supply  all  the  motor  fibres 
to  the  stomach  and  oesophagus.  Vomiting  is  caused  either  by  direct 
irritation  or  reflexly,  as  in  meningitis.  Gastralgia  is  due  either  to 
cramp  of  the  stomach  or  to  direct  irritation  of  the  peripheral  ends  of 
the  vagus. 

The  Spinal  Accessory  Nerve.  The  Eleventh.  The  internal 
branch  joins  the  pneumogastric  nerve  and  passes  to  the  laryngeal  mus- 
cles. The  external  branch  supplies  the  sterno-mastoid  and,  in  part,  the 
trapezius  muscles.  Disease  of  this  nerve  causes  complete  palsy  of  the 
former  and  partial  palsy  of  the  latter  muscle.  The  head  is  rotated 
with  difficulty  to  the  sound  side.  The  shoulder  droops  a  little,  and 
the  angle  of  the  scapula  is  rotated  inward  by  the  rhomboids  and  the 
levator  anguli  scapula?.  There  is  difficulty  in  raising  the  arm,  because 
the  scapula  cannot  be  fixed.     There  is  no  torticollis. 

Spinal  accessory  spasm  (torticollis,  wry-neck)  may  be  congenital. 
The  sterno-mastoid  is  atrophied,  hard,  and  shortened.  In  almost  all 
cases  there  is  facial  asymmetry,  the  palsied  side  being  the  smaller. 

Spasmodic  torticollis  may  be  tonic  or  clonic.  In  the  former,  the 
occiput  is  drawn  toward  the  shoulder  of  the  affected  side,  the  chin  is 
raised,  and  the  face  turned  toward  the  sound  side.     In  the  latter,  the 


866  SPECIAL  DIAGNOSIS. 

head  is  drawn  forcibly  iu  the  same  direction  every  few  minutes.  In 
some  cases  there  is  severe  pain.  The  sterno-mastoid  may  be  affected 
alone  or  with  the  trapezius,  and,  quite  frequently,  with  the  splenitis, 
the  scalenus  and  platysma  myoides,  the  rectus,  and  the  obliquus.  In 
time  the  muscles  become  markedly  hypertrophied.  If  the  muscles  of 
both  sides  are  affected,  the  head  is  drawn  backward.  This  disease  is 
usually  considered  a  functional  neurosis,  but  it  is  probable  that  some 
cases  are  due  to  disease  of  the  cortical  centres. 

The  Hypoglossal  Nerve.  The  Twelfth.  This  is  the  motor  nerve 
of  the  tongue,  and,  to  a  great  extent,  of  the  muscles  attached  to  the 
hyoid  bone.  Palsy  of  the  tongue  may  be  due  to  supranuclear,  nuclear, 
or  infranuclear  disease.  In  the  first  condition  there  is  hemiplegia,  no 
wasting  nor  change  in  the  electrical  reactions.  The  tongue,  when  pro- 
truded, is  turned  toward  the  affected  side.  In  the  second,  the  lesion 
is  apt  to  be  bilateral,  in  which  case  the  tongue  lies  motionless  on  the 
floor  of  the  mouth,  and  speech  and  deglutition  are  much  interfered 
with.  There  are  atrophy  and  reaction  of  degeneration.  The  condition 
is  likely  to  be  part  of  a  general  bulbar  palsy.  .  In  the  third,  only  one 
nerve  is  affected,  and  unilateral  wasting  and  reaction  of  degeneration 
are  present. 

Rarely  there  occurs  a  clonic  spasm,  in  which  the  tongue  is  thrust  in 
and  out  many  times  in  a  minute. 

The  Spinal  Nerves.     Neuritis. 

Traumatic  injury,  exposure  to  cold,  and  poisons,  as  that  of  rheuma- 
tism, gout,  syphilis,  lead,  alcohol,  and  the  toxins  of  specific  diseases, 
as  smallpox,  typhoid  fever,  diphtheria,  and  other  affections,  may  set 
up  inflammation  of  the  nerves.  Xeuritis  may  also  be  caused  by  direct 
action  of  bacteria,  infection  having  been  introduced  through  other 
channels. 

Symptoms.  The  inflammation  may  be  very  intense  and  involve  a 
large  number  of  nerves,  or  only  one  may  be  affected,  and  the  process 
may  be  moderate  in  degree.  The  symptoms,  therefore,  vary.  The 
local  symptoms  are  referred  to  the  affected  nerve  and  to  the  tissue  in 
the  area  of  its  distribution.  Pain  is  the  most  common.  It  is  of  a 
boring  or  burning  character,  and  is  worse  at  night.  It  is  increased 
by  movement,  by  pressure,  and  by  position.  It  may  radiate  to  dis- 
tant parts.  The  pain  may  not  be  confined  to  the  nerve  alone,  but 
extend  to  the  structures  supplied  by  the  nerve.  The  bone  may  be 
tender  on  pressure.  The  nerve,  if  accessible  to  palpation,  is  found  to 
be  swollen  and  extremely  tender.  Vasomotor  symptoms  are  observed. 
The  skin  over  the  affected  nerve  is  red,  and  may  be  cedematous. 
Eruptions  may  occur  in  the  course  of  the  nerve.  Changes  are  observed 
in  the  nails  (see  page  135).  Xurr  bness,  tingling,  and  other  parossthesice 
are  complained  of.  The  area  of  nerve-supply  may  be  hypercesthetic  ; 
sometimes  sensation  is  lost  in  small  areas.  There  is  icasting  of  the 
muscles,  and  paresis,  if  not  paralysis. 

The  general  symptoms  are  moderate,  although  there  may  be  a  chill 
followed  by  high  fever. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  867 

In  chronic  neuritis  pain  and  trophic  changes  in  the  skin  are  the  most 
common  symptoms.  There  is  wasting  of  the  muscles  and  reactions  of 
degeneration  are  found. 

Diagnosis.  Neuritis  must  be  distinguished  from  neuralgia.  In  the 
latter  the  pain  is  intermittent,  the  nerve-trunks  are  not  tender,  while 
points  of  pain  are  more  prominent  in  local  situations.  The  diminution 
of  sensation  is  an  indication  of  neuritis. 

Inflammation  of  Special  Nerves.  The  following  nerves  may  be  the 
seat  of  neuritis:  1.  The  phrenic  nerve — rarely  (see  Dyspnoea).  2. 
Other  nerves  of  the  brachial  plexus  may  be  affected.  One  or  the  entire 
plexus  may  be  affected.  The  symptoms  are  those  of  neuritis  and  of 
paralysis  of  muscles  supplied  by  the  affected  nerve,  a.  The  posterior 
thoracic  nerve.  The  serratus  muscle  is  affected.  The  paralysis  is 
recognized  by  recession  of  the  posterior  edge  of  the  scapula  from  the 
thorax  when  the  arm  is  put  forward,  b.  The  suprascapular  nerve. 
There  is  paralysis  of  the  supra-  and  infra-spinatus  muscle.  Ability 
to  rotate  the  humerus  outward  is  lost.  c.  The  circumflex  nerve.  The 
deltoid  muscle  is  paralyzed.  The  power  of  raising  the  arm  is  lost,  and 
the  shape  of  the  shoulder  is  changed  as  a  result  of  the  atrophy  of  the 
muscle.  This  condition  must  not  be  confounded  with  ankylosis  of  the 
joint.  In  ankylosis  the  scapula  moves  when  the  arm  is  moved.  In 
paralysis  it  remains  fixed,  d.  The  musculocutaneous  nerve.  The  flexors 
of  the  elbow  are  affected.  The  biceps  and  brachialis  muscles  are  par- 
alyzed, e.  The  musculo-spiral  nerve.  The  triceps,  the  muscles  in  the 
back  of  the  forearm,  and  the  extensors  of  the  wrist  and  fingers  are 
affected.  The  symptoms  are  those  of  wrist-drop  when  the  extensors 
are  affected.  The  triceps  muscle  often  escapes,  because  the  nerve  is 
affected  below  the  point  from  which  the  branches  which  supply  the 
muscle  pass  off.  The  power  of  supination  is  also  lost.  The  mus- 
cles waste;  the  extreme  flexion  causes  prominences  about  the  wrist  and 
hand.  There  is  marked  degenerative  reaction.  Sensation  is  variable; 
it  may  be  lost.  This  form  of  neuritis  is  usually  unilateral,  whereas  in 
lead-poisoning  it  is  bilateral.  /.  The  median  nerve.  The  flexors  of 
the  fingers,  the  abductors  and  flexors  of  the  thumb,  the  pronators  and 
the  radio-flexor  of  the  wrist  are  affected.  Pronation  is  markedly  inter- 
fered with;  flexion  of  the  second  phalanges  on  the  first  is  lost.  The 
wrist  is  flexed  toward  the  ulnar  side.  g.  The  ulnar  nerve.  The  ulnar 
flexor  of  the  wrist,  the  ulnar  half  of  the  deep  flexor  of  the  fingers, 
the  muscles  of  the  little  finger,  the  interossei,  and  adductors  of  the 
thumb  are  affected.     Its  sensory  areas  are  also  affected. 

3.  The  nerves  of  the  lower  limb.  The  symptoms  are  limited  to  the 
individual  nerve-trunks  and  their  respective  functional  areas.  The 
nerve  of  the  leg  most  frequently  affected  is  the  sciatic — a  neuritis  of 
common  occurrence.  The  onset  is  sudden,  the  pain  is  extreme;  there 
is  flexion  of  the  leg  in  order  to  prevent  tension  of  the  nerve.  The 
pain  is  intense  in  the  course  of  the  nerve-trunk  from  a  point  above  the 
hip-joint  to  the  back  of  the  foot.  Tenderness  on  pressure  is  extreme. 
Abnormal  sensations  are  very  common.  The  muscles,  especially  the 
calf-muscles,  become  flabby,  and  sometimes  waste. 

It  must  not  be  forgotten  that  neuritis  with  paralysis  of  the  arms  and 


SPECIAL  DIAGNOSIS. 

legs  closely  simulates  diseases  of  the  spinal  cord.  In  the  arms,  par- 
ticularly, muscular  palsy,  wasting,  and  anaesthesia  are  often  of  spinal 
origin.  The  fact  that  the  disease  is  unilateral  and  the  local  symptoms 
of  neuritis  aid  in  the  diagnosis.  Neuritis  must  be  distinguished  from 
writer's  cramp  and  other  occupation-neuroses. 

Multiple  Neuritis. 

Multiple  neuritis  is  a  disease  in  which  a  number  of  nerves  become 
inflamed  simultaneously  or  successively.  The  nerves  most  frequently 
affected  are  those  of  the  arms  and  legs,  particularly  the  musculo-spiral 
and  the  anterior  tibial;  these  become  the  seat  of  pain,  swelling,  and 
tenderness,  and  the  extensor  and  flexor  muscles  supplied  by  them  are 
paralyzed,  producing  wrist-  and  foot- drop.  Excluding  diphtheria, 
leprosy,  and  the  Japanese  disease  known  as  kakke,  the  most  com- 
mon causes  are  chronic  alcoholism,  cold,  and  exposure.  It  is  most 
common  in  middle  life,  and  females  are  said  to  be  more  frequent  victims 
than  males.  It  may  be  acute  or  subacute  in  its  onset;  when  acute  there 
may  be  marked  fever  with  rigors.  The  initial  symptoms  are  usually 
tingling,  numbness,  and  dull  pains  in  the  limbs;  the  pains  increase  in 
severity  and  become  shooting  and  burning,  as  in  simple  neuritis.  The 
muscles  of  the  limbs  are  tender  to  pressure,  and  the  nerve-trunks 
themselves  highly  sensitive  and  sometimes  perceptibly  swollen.  The 
affected  muscles  lose  power,  waste,  and  show  degenerative  reactions. 
The  skin  is  at  first  hypersesthetic,  but  subsequently  often  becomes  anaes- 
thetic to  touch  while  hypersesthetic  to  pain.  The  deep  reflexes  are 
lost,  and  vasomotor  and  trophic  changes  in  the  skin  and  its  appen- 
dages and  in  the  joints  sometimes  occur. 

As  a  rule,  the  disease  increases  in  severity  for  a  few  weeks  and  then 
slowly  improves,  but  palsy  may  persist  for  months;  it  usually  improves 
first  in  the  legs  and  last  in  the  arms.  Death  may  occur  from  extension 
of  the  palsy  to  the  respiratory  muscles,  but  this  is  rare. 

Diseases  of  the  Spinal  Cord  and  its  Membranes.     Meningitis. 

Inflammation  of  the  dura  mater  (external,  or  pachymeningitis)  may 
be  acute  or  chronic.  The  acute  form  is  characterized  by  local  pain  in 
the  back,  increased  by  motion  and  pressure;  by  rigidity  of  the  muscles; 
by  radiating  pains  in  the  trunk  or  limbs,  due  to  pressure  upon  the 
nerve-roots,  and  hence  called  root-pains;  and  by  hyperesthesia  and 
hyperalgesia,  perhaps  followed  by  anaesthesia,  of  the  skin.  In 
proportion  to  the  extent  of  the  irritation  of  the  nerve-roots,  numb- 
ness, tingling,  formication,  twitching,  and  spasm  accompany  the  pain; 
if  the  compression  is  sufficient,  paralysis  of  motion  results,  with  or 
without  loss  or  perversion  of  sensation.  The  paralyzed  muscles  are 
flaccid,  and  reflex  action  is  abolished.  Urine  and  faeces  may  escape 
involuntarily  from  paralysis  of  the  respective  sphincters,  and,  if  the 
patient  survive  long  enough,  bedsores  may  form.  The  disease  is  febrile, 
and,  should  pus  form,  the  fever  becomes  high  and  is  accompanied  by 
chills  and  sweating:. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  869 

A.s  the  disease  is  almost  always  consecutive  to  disease  of  the  verte- 
brae, such  as  caries  or  traumatism,  or  to  extension  of  suppuration  from 
adjacent  tissues,  as  in  bedsores,  the  early  symptoms  are  liable  to  be 
overlooked  in  the  primary  affection. 

Gowers  says  that  in  cases  of  apparently  primary  meningitis  a  care- 
ful watch  should  be  kept  on  the  tissues  of  the  back;  any  sign  of  deep 
oedenia  in  the  muscles  beside  the  vertebral  column,  in  such  a  case,  is 
probably  evidence  of  commencing  purulent  inflammation  extending 
from  within;  and  the  development  of  acute  local  inflammation  in  either 
the  pleura,  posterior  mediastinum,  back  of  the  abdomen,  or  behind 
the  pharynx  has  the  same  significance. 

The  chronic  form  is  characterized  by  the  same  symptoms  of  local 
vertebral  pain,  radiating  root-pains  with  disturbances  of  sensation, 
together  with  symptoms  of  pressure  on  the  cord.  The  pain  is  less 
acute,  and  the  course  of  the  disease  much  longer. 

Inflammation  of  the  pia  and  arachnoid  (internal,  or  leptomeningitis) 
may  be  acute  or  chronic. 

The  acute  form  is  characterized  at  its  onset  by  chill,  fever,  and  local 
vertebral  pain,  rarely  preceded  by  other  symptoms.  The  pain  rapidly 
becomes  intense,  and  is  aggravated  by  motion;  it  is  felt  over  a  consid- 
erable portion  of  the  spine,  but  is  often  worse  in  one  part.  In  addi- 
tion to  the  local  pain,  there  are  root-pains  of  great  intensity,  shooting 
into  the  trunk  and  extremities.  There  is  a  tendency  to  muscular 
spasm,  showing  itself  first  in  stiffness  of  the  muscles  of  the  back,  often 
causing  rigidity  and  retraction  of  the  head,  and  sometimes  opisthotonos. 
Elsewhere  the  muscular  spasm  is  exhibited  in  painful  cramp  of  the 
abdominal  muscles  and  muscles  of  the  extremities.  The  latter  become 
rigid,  painful  on  pressure,  and  are  liable  to  painful  cramp  like  spasms 
on  motion.  The  skin  is  hypersesthetic,  and  reflex  action,  both  of  the 
skin  and  muscles,  is  increased.  The  bowels  are  constipated  and  the 
urine  retained,  from  spasm  of  the  sphincters.  Spasm  of  the  chest- 
muscles  sometimes  causes  intense  dyspnoea.  Swallowing,  also,  may  be 
difficult.  If  the  inflammation  extends  to  the  medulla,  cerebral  symp- 
toms are  superadded,  such  as  delirium  and  coma.  If  the  disease  pro- 
gresses unfavorably,  the  irritative  symptoms  give  way  to  paresis  and 
then  to  paralysis,  accompanied  by  loss  of  sensation  and  reflex  action. 
Recovery  may  occur  at  this  stage,  with  gradual  abatement  of  the  pain 
and  slow  regaining  of  muscular  power;  or  death  may  result  from  weak- 
ness and  failure  of  respiratory  power,  or,  more  slowly,  as  the  result 
of  complications,  such  as  bedsores  and  nephritis.  The  disease  may  also 
pass  into  a  subacute  or  chronic  form,  loss  of  power  gradually  taking  the 
place  of  the  irritative  symptoms,  and  atrophy  and  contractions  appear- 
ing. The  final  result  may  be  a  chronic  myelitis,  or  complete  but  very 
gradual  recovery. 

The  disease  is  febrile,  but  the  temperature  may  be  only  slightly 
above  normal.  The  duration  of  the  disease  is  from  a  few  days  to  two 
or  three  weeks;  but  disturbances  of  motion  and  sensation  may  persist 
for  months,  or  even  become  permanent. 

The  disease  may  be  traumatic  in  origin,  or  it  may  arise  from  exposure 
to  cold  or  heat,  including  long-continued  exposure  to  the  sun.    It  may 


870  SPECIAL  DIAGNOSIS. 

also  be  secondary  to  an  external  meningitis  or  to  a  cerebral  meningitis, 
or  it  may  be  septic  in  origin. 

Chronic  meningitis  differs  widely  in  its  symptoms  from  the  acute 
form,  particularly  in  the  fact  that  spasm  is  almost  wholly  absent. 
There  is  local  pain  in  the  back  which,  as  in  acute  meningitis,  is  in- 
creased by  pressure  and  motion;  but  the  pain  is  not  so  acute.  The 
muscles  are  more  rigid  than  normally,  and  there  may  be  retraction  of 
the  head.  Root-pains  are  severe  and  of  varied  character.  Hyperes- 
thesia to  pain  and  touch  may  be  marked.  Muscular  twitchings  may 
occur,  but  they  are  not  pronounced,  and  rarely  amount  to  spasms. 
The  parts  affected  by  the  radiating  pains  will,  of  course,  depend  upon 
the  seat  of  the  lesion. 

After  the  lapse  of  weeks  or  months  loss  of  power  occurs  in  the 
affected  muscles.  The. radiating  pain  may  continue  or  disappear.  The 
paralytic  phenomena  are  progressive,  the  muscles  waste,  reflex  action 
is  abolished  finally,  sensation  is  impaired,  at  least  in  the  affected  muscles. 
If  the  inflammation  involves  the  lumbar  enlargement,  reflex  action  is 
lost  and  atrophy  of  the  legs  occurs;  whereas,  it  it  is  above  the  lumbar 
enlargement,  the  reflexes,  if  lost  temporarily,  are  regained,  and  wasting 
of  the  leg-muscles  does  not  occur. 

Gowers  says  that  in  the  trunk  loss  of  reflex  action  with  anaesthesia 
is  of  much  diagnostic  importance.  There  may  also  be  some  loss,  of 
coordination. 

Cervical  hypertrophic  pachymeningitis  (Charcot  and  Joffroy)  closely 
simulates  progressive  muscular  atrophy.  Its  earlier  stage  is  character- 
ized by  pain  in  the  back  of  the  head,  neck,  shoulders,  and  arms,  fol- 
lowed by  wasting  of  groups  of  muscles  of  the  arm  and  hand,  leading 
to  the  deformity  known  as  main-en-griffe  (claw-hand),  and  to  weakness 
and  wasting  of  the  muscles  of  the  leg. 

Chronic  syphilitic  meningitis  is  characterized  by  a  tendency  of  the 
inflammation  to  localize  itself  in  one  part,  and,  hence,  by  unilateral 
radiating  pains,  ausesthesia,  and  paresis. 

Meningitis  is  to  be  distinguished  from  muscular  rheumatism,  mye- 
litis, and  tetanus.  In  muscular  rheumatism  of  the  back  the  pain  is 
local,  and,  while  increased  by  pressure  and  especially  by  motion,  it  is 
not  accompanied  by  shooting-pains  in  the  trunk  and  limbs,  nor  by 
disturbances  of  sensation  and  motion;  moreover,  fever  is  moderate  or 
absent. 

In  myelitis  without  accompanying  meningitis  local  vertebral  and 
root-pains  are  slight  or  absent  entirely;  paralysis  occurs  early,  and  is 
not  accompanied  by  spasm. 

In  tetanus  initial  fever  is  absent,  the  jaw-muscles  are  early  affected 
with  tonic  spasm  (trismus),  and  general  muscular  spasms  are  easily 
provoked  by  touch  or  motion. 

The  symptoms  of  chronic  meningitis  vary  according  to  whether  the 
dura  {pachymeningitis)  or  the  pia  and  arachnoid  {leptomeningitis)  are 
principally  involved;  also  according  to  the  extent  of  irritation  of  the 
nerve-roots  and  involvement  of  the  cord.  In  leptomeningitis  local 
pain  in  the  back,  stiffness  of  the  muscles,  and  hyperesthesia  of  the 
skin  are  more  marked  than  in  pachymeningitis.     Nevertheless,  root- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  871 

pains  are  present,  and  paresis  of  the  legs  from  involvement  of  the 
cord  sometimes  occurs  early.  In  pachymeningitis,  on  the  other  hand, 
local  vertebral  symptoms  are  subordinated  to  the  root- symptoms,  and 
muscular  atrophy  may  be  marked. 

In  general,  the  symptoms  dependent  upon  irritation  or  structural 
alteration  of  the  nerve-roots  are  the  most  important  for  diagnostic  pur- 
poses, and,  when  taken  in  connection  with  the  vertebral  symptoms  and 
their  mode  of  onset,  are  generally  sufficient  to  differentiate  the  disease 
from  the  affections  with  which  it  might  be  confounded. 

Meningeal,  Hemorrhage.  This  may  be  between  the  dura  mater 
and  the  vertebra  (extrameningeal),  or  within  the  dura  (intramenin- 
geal) ;  the  former  is  more  common.  The  symptoms  resemble  those  of 
meningitis,  but  are  more  sudden  and  violent.  Pain  in  the  back  is 
severest,  usually,  at  a  point  corresponding  to  the  seat  of  hemorrhage. 
As  in  meningitis,  there  are  pains  shooting  into  the  limbs,  with  numb- 
ness, tingling  or  formication,  muscular  spasms,  and  paresis,  or  para- 
plegia; when  the  hemorrhage  is  small,  there  may  be  only  paresthesia 
and  paresis  of  the  extremities.  If  the  hemorrhage  is  large,  there  may 
be  immediate  paraplegia.  As  a  rule,  paralysis  does  not  become  com- 
plete. 

The  hemorrhage  may  be  due  to  traumatism,  to  severe  convulsions, 
violent  exertion,  or  rupture  of  an  aneurism. 

It  needs  to  be  distinguished  from  hemorrhage  into  the  cord  and  from 
meningitis.  In  the  former  case  vertebral  pain  is  not  so  prominent  a 
symptom  as  in  meningeal  hemorrhage,  and  is  not  usually  so  extensive. 
On  the  other  hand,  paralysis  is  immediate,  not  gradual  in  onset,  though 
it  may  be  slight  at  first  and  then  extend  rapidly.  Spasm  is  absent  in 
hemorrhage  into  the  cord,  aud  recovery  from  the  paralysis  is  more  grad- 
ual. If  hemorrhage  involve  both  membranes  and  cord,  the  symptoms 
of  both  lesions  will,  of  course,  be  seen  together. 

The  absence  of  fever  helps  to  distinguish  hemorrhage  into  the  cord 
from  meningeal  hemorrhage.  Moreover,  the  symptoms  iu  the  latter 
disease  are  of  a  more  gradual  onset.  The  lesion  that  causes  the  hem- 
orrhage may,  however,  also  cause  a  meningitis,  in  which  case  the 
symptoms  of  the  latter  will  follow  those  of  the  hemorrhage. 

Hyperemia.  Hypercemia  of  the  spinal  cord  is  indicated  by  a  feel- 
ing of  fulness,  weight,  or  aching  in  the  back,  by  parsesthesia  of  vari- 
ous kinds,  and  perhaps  by  some  increase  in  the  reflexes,  a  feeling  of 
heaviness  in  the  limbs,  and  some  motor  weakness.  The  symptoms  are 
relieved  when  the  patient  lies  prone.  Active  congestion  must  occur 
from  excessive  stimulation  of  the  cord  and  motor  nerves — as  in  con- 
vulsions, excessive  muscular  exercise,  or  over-frequent  coitus— be- 
cause we  know  that  such  conditions  produce  hemorrhage;  but  the 
symptoms  merge  into  those  of  incipient  inflammation  so  as  to  be  prac- 
tically inseparable  from  it. 

Anjemia.  Ancemia  of  the  cord  is  difficult  to  distinguish  with  suffi- 
cient definiteness  except  in  general  anaemia,  or  anaemia  from  sudden 
hemorrhage.  Iu  these  conditions  there  is  paresis  of  muscles,  which 
may  result  in  complete  paralysis  from  subsequent  degeneration  of  nerve- 
elements.      Sensation  is  usually  not  disturbed. 


872  SPECIAL  DIAGNOSIS. 


Compression  of  the  Spinal  Cord. 

Compression  of  the  spinal  cord  is  most  frequently  the  result  of  caries 
or  fracture  of  the  spinal  column;  but  it  occurs  also  in  morbid  growths, 
aneurism,  and  other  conditions. 

Pain  is  a  prominent  symptom;  it  is  ueuralgic  in  character,  and  may 
be  felt  in  the  arm,  or  leg,  or  in  the  trunk,  in  this  locality  giving  rise 
to  the  so-called  girdle-pains.  Other  symptoms  are  hyperesthesia  of 
the  skin,  followed  by  anesthesia  in  places,  without  cessation  of  the 
pain  ("anesthesia  dolorosa").  There  are  more  likely  to  be  motor 
weakness  and  atrophy  than  spasm.  The  motor  weakness  is  at  first 
overshadowed  by  the  shooting-pains,  and,  as  a  rule,  deepens  gradually 
into  paralysis;  but  if  the  compression  gives  rise  to  myelitis,  paralysis 
occurs  rapidly.  The  reflexes  that  are  completed  in  the  segments  below 
the  compression  are  exaggerated.  Sensation  may  or  may  not  be  im- 
paired below  the  level  of  the  compression.  The  symptoms  are  very 
rarely  unilateral,  though  one  limb  is  frequently  affected  first,  and  to  a 
greater  degree  than  the  other. 

The  diagnosis  is  based  upon  the  existence  of  irritation  of  the  nerve- 
roots  and  cord,  and  upon  the  detection  of  some  compressing  cause. 
When  the  vertebre  are  diseased  there  is  considerable  local  tenderness 
as  well  as  pain,  which  is  decidedly  increased  by  movement.  Addi- 
tional diagnostic  points  are  slow  development,  increase  of  reflexes, 
invasion  of  one  side  before,  and  to  a  greater  degree  than,  the  other. 

As  to  the  cause  of  the  compression,  Gowers  states  that  if  the  patient 
is  in  the  first  half  of  life  and  inherits  a  tubercular  tendency,  caries  is 
suggested.  The  absence  of  root-symptoms  is  also  in  favor  of  caries, 
but  their  presence  does  not  argue  against  caries,  unless  the  pain  is 
extremely  severe  and  is  greatly  increased  by  movement. 

Recovery  will  depend,  for  the  most  part,  upon  the  persistency  or 
increase  of  the  compression.  If  it  is  removed,  or  even  if  it  ceases  to 
increase,  recovery  is  often  complete. 

Myelitis. 

Myelitis,  or  inflammation  of  the  spinal  cord,  may  be  acute  or  chronic. 
It  may  involve  the  entire  thickness  of  the  cord  through  a  short  seg- 
ment {transverse  myelitis);  it  may  involve  continuously  a  large  section 
of  the  cord  (diffuse  myelitis);  or  scattered  areas  may  be  affected  {dis- 
seminated myelitis);  or  one  small  area  may  alone  be  the  seat  of  inflam- 
mation {focal  myelitis);  when  the  gray  matter  is  wholly  or  chiefly 
involved  it  is  called  poliomyelitis. 

Acute  Transverse  Myelitis  is  characterized  by  the  rapid  devel- 
opment of  paralytic  symptoms,  impairment  or  loss  of  sensation,  a  girdle 
sensation  at  the  level  of  the  lesion,  either  increase  or  loss  of  reflex  action, 
more  or  less  atrophy  of  the  affected  muscles,  and  paralysis  of  the 
sphincters.  The  disease  may  be  ushered  in  by  fever,  headache,  deli- 
rium, or  gastric  derangement;  by  rheumatoid  pains;  by  paresthesia  in 
the  limbs;  or  it  may  develop  abruptly  with  a  convulsion.      Convul- 


DISEASES  OF  THE  XEBVOUS  SYSTEM.  873 

sions,  however,  are  rare,  except  in  children.  Vertebral  pain  is  rarely 
marked  and  may  be  absent  entirely. 

Ketention  of  urine  is  a  very  significant  and  important  early  symp- 
tom. The  paralytic  phenomena  begin  by  a  feeling  of  weight  and 
weariness  in  the  limbs,  possibly  accompanied  by  numbness  and  ting- 
ling. If  the  patient  is  walking,  he  may  be  obliged  to  sit  down  to  rest 
and  then  find  himself  unable  to  get  up  again,  when  he  makes  the 
attempt.  More  frequently  the  paraplegia  develops  more  gradually  and 
becomes  complete  only  after  the  lapse  of  some  days.  In  other  cases, 
after  paresis  has  existed  for  several  days,  paralysis  supervenes  some- 
what suddenly. 

Paralysis  of  sensation  may  be  complete,  or  impaired  in  different 
ways.  Sensibility  to  touch  may  be  lost  while  pain  is  felt.  A  hyper- 
sesthetic  zone  usually  exists  immediately  above  the  lesion,  and  its  seat 
is  detected  by  passing  a  hot  sponge  down  the  spine.  When  opposite 
the  zone  the  sense  of  warmth  becomes  one  of  pain.  The  girdle-sen- 
sation is  felt  at  the  same  level. 

The  condition  of  the  reflexes  and  of  the  nutrition  of  the  muscles 
depends  largely  upon  the  seat  of  the  lesion.  If  the  lumbar  enlarge- 
ment is  involved  in  the  inflammation,  the  reflexes  are  abolished  and 
atrophy  speedily  follows.  If  above  the  lumbar  enlargement,  the  reflexes 
may  be  lost  temporarily,  but  are  subsequently  regained  and  become 
exaggerated,  while  atrophy  does  not  occur  to  any  great  extent. 

At  first  the  urine  and  fseces  are  retained,  but  later  they  are  passed 
involuntarily.  Trophic  changes  in  the  skin  predispose  to  ulceration 
and  bedsores.  Severe  cystitis  is  not  uncommon.  Fever  is  present 
during  the  progressive  stage  of  the  disease,  but  is  usually  slight — 99° 
to  101°. 

The  initial  lesion  may  be  the  only  one,  or  the  inflammation  may 
extend  upward  or  downward;  or,  again,  after  apparent  convalescence, 
there  may  be  a  fresh  outbreak.  In  cases  that  end  in  recovery  sensa- 
tion is  regained  in  the  course  of  a  few  weeks  or  months,  and  eventually 
motion  also.     Spastic  paraplegia  may  result. 

Acute  myelitis  may  result  in  death  or  in  recovery,  and  the  latter 
may  be  complete  or  incomplete.  Death  may  occur  early  from  inter- 
ference with  respiration,  or  later  from  the  involvement  of  the  medulla 
by  disseminated  myelitis,  or  the  immediate  cause  may  be  disease  of  the 
kidneys  or  of  other  organs,  or  exhaustion  or  septicaemia  from  bedsores; 
when  the  patient  does  recover,  his  strength  comes  back  slowly. 

Disseminated  Myelitis  is  characterized  usually  by  the  consecutive 
development  of  symptoms  pointing  to  lesion  of  the  cord  at  different 
levels.  An  exact  diagnosis  depends  on  the  ability  to  differentiate  the 
symptoms  produced  by  various  local  lesions.  Growers  states  that  the 
onset  of  this  form  is  often  subacute,  and  that  constitutional  symptoms 
may  be  absent. 

"An  inflammation  which  continues  to  extend  after  the  first  two  or 
three  days  is  certainly  disseminated,  and  most  subacute  cases  are  of 
this  variety,  and  so  are  those  that  are  secondary  to  blood-states.  The 
distinction  is  important,  because  this  form  is  far  more  grave  than  any 
other  and  more  likely  to  cause  death." 


874  SPECIAL  DIAGNOSIS. 

Central  Myelitis  is  the  name  given  to  inflammation  of  the  gray 
matter  surrounding  the  central  canal  of  the  cord.  It  is  characterized 
by  violence  of  onset  and  by  a  rapidly  fatal  course.  There  are  complete 
paraplegia  and  complete  loss  of  sensation  in  the  lower  limbs;  the 
sphincters  are  paralyzed  and  reflex  action  abolished.  Moreover,  the 
affected  muscles  atrophy  with  great  rapidity.  Fever  is  marked,  and 
death  usually  occurs  in  a  few  days. 

Acute  myelitis  may  arise  from  traumatism,  from  hemorrhage,  or  it 
may  be  secondary  to  meningitis.  It  may  also  arise  from  cold,  particu- 
larly from  lying  upon  the  back  on  damp  ground;  from  over-stimula- 
tion of  the  cord  by  sexual  excesses;  in  the  course  of  or  during  con- 
valescence from  the  infectious  fevers;  and  under  the  influence  of  gout, 
syphilis,  and  alcoholism. 

Chronic  Myelitis.  Chronic  myelitis,  called  diffuse  myelitis,  dif- 
fuse sclerosis,  chronic  transverse  myelitis,  presents  symptoms  differing 
from  those  of  acute  myelitis  chiefly  in  their  slow  onset.  Its  essential 
characteristics  are  the  impairment  of  motion  and  of  sensation,  pares- 
thesia and  sometimes  dull  pains  in  the  legs,  a  decided  girdle-sensation, 
exaggeration  of  the  reflexes,  and,  usually,  not  much  atrophy. 

The  patient  finds  that  the  legs  are  heavy,  and  that  they  become  tired 
easily.  He  walks  slowly,  does  not  lift  his  feet  clear  of  the  ground, 
but  is  inclined  to  drag  them.  The  muscles  become  rigid,  and,  as  they 
grow  weaker,  the  reflexes  are  exaggerated  until  a  condition  of  spastic 
paraplegia  is  reached.  Sometimes  there  is  loss  of  coordinating  power, 
but  no  true  ataxia.  Constipation  and  slowness  and  difficulty  in  mic- 
turition indicate  the  impairment  in  expulsive  power  of  the  rectum  and 
bladder.  Sensation  is  not  lost  to  the  same  extent  as  motion.  There 
is  often  a  constant  dull  pain  in  the  back,  and  the  affected  limbs  may 
be  the  seat  of-  tingling,  numbness,  and  formication.  There  is  usually 
well-  marked  girdle-sensation . 

The  disease  may  be  widely  scattered,  and  hence  almost  every  symp- 
tom of  spinal  involvement  may  be  met  with. 

If  the  gray  matter  is  involved  (chronic  poliomyelitis),  there  are  atro- 
phy, anaesthesia,  and  paralysis.  These  develop  with  greater  or  less 
rapidity,  sometimes  involving  the  legs  first  and  then  the  arms,  and 
sometimes  the  arms  first  and  then  descending. 

The  duration  of  chronic  myelitis  is  unusually  long.  It  may  progress 
steadily  and  uniformly,  or  at  times  grow  worse  rapidly;  or  the  disease 
may  be  arrested  at  any  period,  and  become  stationary.  Its  duration 
is,  therefore,  extremely  indefinite,  varying  from  one  to  twenty  years. 
Spitzka  states  that  the  duration  is  from  six  to  fifteen  years. 

Chronic  myelitis  is  differentiated  from  hysterical  paraplegia  by  the 
presence  of  degenerative  reaction  in  the  muscles,  and  h\  the  fact  that 
incontinence  of  the  urine  is  more  common  in  myelitis,  while  in  hyster- 
ical paraplegia  retention  is  the  rule;  by  the  absence  of  pupillary  phenom- 
ena in  the  latter;  and  by  the  fact  that  anaesthesia,  if  present  in  hysteria, 
is  less  likely  to  correspond  with  the  distribution  of  the  motor  paralysis. 
Moreover,  the  hysterical  patient  can  overcome  the  paraplegia  to  a  con- 
siderable degree  by  a  strong  effort  of  the  will. 

From  compression  of  the  cord  it  is  distinguished  by  absence  of  any 


DISEASES  OF  THE  NERVOUS  SYSTEM.  875 

obvious  cause  of  pressure,  such  as  injury  or  caries  of  the  vertebrae,  and 
by  absence  of  root-pains,  which  would  indicate  that  the  process  had 
begun  outside  the  cord. 

From  tumor  of  the  cord  it  is  distinguished  by  the  comparative  absence 
of  root-pains.  Either  may  involve  one-half  of  the  cord  more  than 
the  other,  but  myelitis  is  more  likely  than  tumor  to  present  absolutely 
unilateral  symptoms. 

From  primary  lateral  sclerosis  (spastic  paraplegia)  it  is  distinguished 
by  the  existence  of  both  motor  and  sensory  impairment,  whereas  in 
spastic  paraplegia  the  symptoms  are  entirely  motor. 

From  progressive  muscular  atrophy  it  is  distinguished  by  the  fact  that 
atrophies  of  myelitis  are  irregularly  distributed,  while  those  of  pro- 
gressive muscular  atrophy  are  symmetrical.  Moreover,  in  the  former 
there  are  other  cord-symptoms  and  sensory  disturbances. 

Pachymeningitis  is  distinguished  principally  by  greater  pain  and  by 
a  more  pronounced  and  extensive  anaesthesia.  Gowers  says  that  if 
there  are  similar  symptoms  in  both  arms  and  legs,  myelitis  is  far  more 
probable  than  pachymeningitis,  since  the  chronic  inflammation  of  the 
membranes  is  less  extensive  than  that  of  the  cord. 

Anterior  Poliomyelitis.  This  disease  is  also  called  atrophic 
spinal  paralysis,  infantile  spinal  paralysis,  etc.  Children  up  to  the 
fifth  year  are  most  frequently  attacked,  and  more  commonly  in  summer 
than  in  winter.  Its  essential  characteristic  is  suddenness  of  onset  with 
complete  paralysis,  which  speedily  abates  to  a  certain  extent,  leaving 
certain  muscles  or  groups  of  muscles  permanently  paralyzed;  these 
waste  rapidly  and  progressively,  and  lose  their  electrical  contractility. 
Sensation  is  undisturbed,  the  sphincters  remain  unaffected,  trophic  dis- 
turbances of  the  skin  are  absent,  and  the  intellect  is  not  involved. 
The  affected  muscles  subsequently  undergo  contracture. 

The  onset  of  the  disease  may  be  marked  by  fever,  which  is  usually 
moderate,  by  convulsions  or  delirium,  by  rheumatoid  pains;  or  it  may 
appear  without  warning  of  any  kind,  either  during  the  day,  or  in  the 
morning  after  a  quiet  night.  Fever,  if  it  occurs  at  all,  rarely  precedes 
the  paralysis  more  than  a  day  or  two.  Sometimes  the  disease  develops 
during  the  course  of,  or  during  convalescence  from,  one  of  the  specific 
fevers.  The  extent  of  the  paralysis  varies;  it  may  involve  only  one 
limb,  or  all  four  limbs  and  the  trunk.  If  the  child  has  been  ill,  or  if  the 
early  symptoms  have  compelled  the  child  to  go  to  bed,  paralysis  may 
be  detected  first  when  the  child  gets  up,  previous  disability  being  attrib- 
uted to  geueral  weakness  or  lack  of  energy.  The  paralysis  rapidly 
attains  its  greatest  extent,  often  in  a  few  hours;  it  remains  unchanged 
for  from  two  to  six  weeks,  and  then  begins  to  abate  in  the  inverse 
order.  That  is  to  say,  if  the  arm  was  first  affected  and  the  leg  last, 
the  paralysis  in  the  leg  will  begin  to  improve  first.  This  order  of  im- 
provement is  characteristic,  and  led  Barlow  to  call  the  disease  "  regres- 
sive paralysis."  All  the  affected  muscles  do  not  recover.  Those 
which  remain  permanently  paralyzed  waste  rapidly  and  display  degen- 
erative reaction. 

The  superficial  reflexes  are  lost,  but  there  is  no  loss  of  sensation, 
although  pallesthesia  may  be  felt.     The  bones  may  cease  to  grow  in 


876  SPECIAL  DIAGNOSIS. 

the  affected  limb,  which  therefore  becomes  shortened  relatively  to  its 
fellow.     Contractions  are  a  late  result. 

Acute  Ascending  Paralysis.  Acute  ascending,  or  Landry's 
paralysis,  is  characterized  by  a  rapid  and  progressive  paralysis,  begin- 
ning usually  in  the  feet  and  extending  upward,  involving  the  muscles 
of  the  trunk,  chest,  arms,  and  neck;  swallowing  and  speech  may  be 
abolished.  Sensation  is  practically  unaffected,  though  there  may  be 
paresthesia  and  hyperesthesia  of  the  skin.  Reflex  action  may  or  may 
not  be  regained. 

The  muscles  are  toneless  and  are  neither  atrophied  nor  changed  in 
their  electrical  reactions.  The  disease  is  afebrile.  Enlargement  of 
the  spleen  has  been  noted  in  several  cases. 

The  disease  is,  as  a  rule,  rapidly  fatal,  most  of  the  patients  dying 
within  a  week;  but  it  may  last  several  weeks,  and  recovery  is  not 
impossible. 

The  disease  is  believed  to  be  a  peripheral  neuritis. 

Diver's  Paralysis.  Diver's  paralysis  is  generally  a  paraplegia; 
it  comes  on  in  persons  who  have  remained  at  a  considerable  depth  below 
the  surface  of  the  water  for  at  least  an  hour.  It  is  more  apt  to  occur 
after  the  diver  has  returned  to  the  air  than  while  he  is  in  the  water. 
It  usually  comes  on  very  rapidly,  sensation  as  well  as  motion  being 
lost,  and  the  lower  half  of  the  body  feeling  numb  and  foreign  to  the 
patient.  Recovery  generally  occurs  in  from  three  to  ten  days,  but  it 
may  be  much  slower  than  this,  and  paralysis  may  in  rare  cases  be 
permanent.     Death  occurs  occasionally. 

Hemorrhage  into  the  Spinal  Cord. 

Hemorrhage  into  the  spinal  cord,  or  hsematomyelia,  is  extremely 
rara  clinically.  The  symptoms  produced  are  those  already  described 
as  occurring  in  acute  transverse  myelitis,  from  which  the  essential  point 
of  difference  is  the  great  suddenness  of  onset.  It  may  arise  from 
injury,  overexertion,  and  sexual  excess. 

The  prognosis  depends  upon  the  size  of  the  hemorrhage  and  upon 
its  seat,  and  is  better  in  proportion  to  the  rapidity  with  which  sensation 
is  regained.     Myelitis  may,  however,  be  a  secondary  result. 

Degenerations  of  the  Spinal  Cord. 

1.  Locomotor  ataxia. 

2.  Primary  spastic  paraplegia. 

3.  Ataxic  paraplegia. 

4.  Chronic  muscular  atrophy. 

5.  Arthritic  muscular  atrophy.  - 

Locomotor  Ataxia.  Locomotor  ataxia,  frequently  called  tabes 
dorsalis,  also  posterior  sclerosis,  is  a  chronic  degenerative  disease  of  the 
spinal  cord,  involving  the  posterior  columns  aud  root-fibres,  and  char- 
acterized by  lightning-pains,  usually  felt  in  the  legs,  by  the  absence  of 
knee-jerk,  by  incoordination  of  movement  without  paralysis  or  mus- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  877 

cular  wasting,  by  the  Argyll-Robertson  pupil,  vesical  and  rectal  dis- 
turbances, and  loss  of  sexual  power. 

The  lightning-pains  and  loss  of  knee-jerk  precede  the  incoordination, 
which  is  very  rarely  absent. 

Incoordination  of  movement  develops  gradually.  The  patient  first 
notices  that  at  night  he  cannot  walk  without  stumbling,  though  during 
the  day  he  walks  well  enough.  Or  he  may  not  have  noticed  any  loss 
of  coordination  himself,  but,  when  he  is  examined  by  the  physician, 
and  asked  to  close  his  eyes  and  then  walk,  he  staggers  and.  even  falls 
unless  supported;  and  if  he  is  directed  to  place  his  feet  close  together 
and  close  his  eyes,  he  sways  considerably  (Romberg's  sign).  The 
reason  for  this  is  that  the  muscular  sense  and  sense  of  position  are  defi- 
cient, and  without  the  guidance  of  vision  the  patient  cannot  tell  where 
he  is.  By  degrees  incoordination  becomes  manifest,  even  when  the 
eyes  are  open.  The  gait  becomes,  in  time,  characteristic;  the  leg  is 
thrown  laterally  and  forward  with  a  jerk,  and  then  brought  down  sud- 
denly and  forcibly,  the  whole  sole  striking  the  ground.  Finally,  he 
may  be  unable  to  rise  to  his  feet,  as  any  attempt  to  rise,  or  contact  of 
his  feet  with  an  object,  produces  spasmodic,  pendulum-like  motions. 
Incoordination  may  affect  the  arms  also,  but  almost  always  after  the 
legs  have  been  affected.  Ataxia  may  be  developed  on  making  attempts 
to  write,  or  to  button  or  unbutton  the  coat.  The  muscles  retain  their 
power,  except  in  advanced  cases,  when  there  may  be  some  weakness. 

Disturbances  in  sensation  are  very  marked  and  are  very  rarely  absent. 
Darting-pains  in  the  legs,  called  from  their  suddenness  and  severity 
"  lightning  "-pains,  are  characteristic.  They  are  paroxysmal,  and, 
while  usually  felt  in  the  legs,  may  shoot  into  the  arms,  head,  or  other 
parts.  The  pains  are  not  always  lightning  in  character,  but  may  be 
ordinary  neuralgic  or  rheumatoid  pains.  Painful  girdle-sensations 
may  be  felt  in  the  trunk  and  limbs.  Paresthesia?  are  frequently  com- 
plained of  and  partial  anaesthesia  is  common  later  on,  in  well-marked 
cases.     The  perception  of  sensation  may  be  considerably  retarded. 

The  cutaneous  reflexes  are  usually  lessened,  but  may  be  greatly  ex- 
aggerated in  the  early  stages.  Loss  of  sexual  power  is  the  rule;  it 
may  occur  early  in  the  disease,  or  be  a  sequel  to  abnormally  increased 
passion.  The  deep  reflexes,  particularly  the  knee-jerk,  are  almost 
invariably  absent  in  the  affected  territory. 

The  rectum  and  bladder  are  more  often  sluggish  in  action  than  par- 
alyzed. The  eye-symptoms  are  optic  atrophy,  paralysis  of  the  ocular 
muscles,  and  the  Argyll-Robertson  pupil — i.e.,  a  pupil  which  contracts 
to  accommodation  but  not  to  light.  Ptosis  and  diplopia  often  occur 
as  early  symptoms,  but  may  disappear  during  the  subsequent  course  of 
the  disease. 

A  great  variety  of  vasomotor  and  trophic  symptoms  may  be  present, 
such  as  oedemas,  local  sweatings,  skin  eruptions,  atrophies,  and  joint- 
changes.  The  teeth  sometimes  fall  out  painlessly.  The  arthropathies 
occur  as  painless  enlargements  of  the  joints,  with  undue  motility;  the 
knee  being  most  commonly  affected. 

The  term  crisis  is  used  in  tabes  to  describe  the  paroxysmal  derange- 
ments of  the  functions  of  various  organs  which  occur  in  the  disease. 


878  SPECIAL  DIAGNOSIS. 

The  most  common  are  gastric  crises,  in  which  there  is  severe  pain  in 
the  stomach,  followed  by  vomiting,  which  may  or  may  not  be  attended 
by  nausea.  Any  organ  may  be  subject  to  corresponding  crises;  thus 
we  have  at  times  laryngeal,  rectal,  and  vesical  crises. 

The  course  of  the  disease  is  extremely  chronic.  Gowers  says  it  is 
exceedingly  common  for  the  first  stage — in  which  there  is  no  alteration 
in  gait,  but  loss  of  knee-jerk,  pain,  often  Argyll-Robertson  pupil,  and 
unsteadiness  on  standing  with  the  feet  together  and  the  eyes  shut — to 
last  for  from  ten  to  twenty-five  years.  He  does  not  think  the  disease 
shows  a  progressive  tendency  in  more  than  half  the  cases  in  which  it 
is  recognized  early  and  carefully  treated. 

There  is  no  general  rule  in  the  matter  of  progress.  Often  one 
symptom  improves,  and  another  appears  or  is  aggravated.  The  dis- 
ease itself  is  not  fatal.  Death  may  result  from  complications  involv- 
ing the  kidneys  and  heart,  or  from  some  other  nervous  disease.  As 
the  primary  cause  of  locomotor  ataxia  is  in  most  cases  syphilis,  any  other 
tertiary  or  secondary  manifestation  of  syphilis  may  be  found  to  coexist. 

Primary  Spastic  Paraplegia.  Primary,  spastic  paraplegia,  or 
primary  lateral  sclerosis,  is  a  chronic  degenerative  disease  of  the  cord, 
probably  involving  the  pyramidal  tracts  or  their  terminations  in  the 
gray  matter.  It  is  characterized  by  gradually  developing  loss  of  motor 
power  in  the  lower  extremities,  spasmodic  contractions  of  the  muscles, 
with  exaggerated  reflexes,  absence  of  wasting,  maintenance  of  sensa- 
tion, involvement  of  the  sphincters,  and  a  very  chronic  course. 

The  combination  of  rigidity  with  spasm  makes  the  gait  peculiar. 
In  fully  developed  cases  the  patient  cannot  easily  bring  the  foot  for- 
ward; it  drags  behind  and  the  toe  has  a  tendency  to  stick  into  the 
ground ;  and,  as  clonus  is  easily  excited,  there  may  be  spasmodic  con- 
tractions after  the  foot  touches  the  ground.  Sensation  is,  as  a  rule, 
maintained  undisturbed,  but  paresthesia  may  be  present. 

The  arms,  as  well  as  the  legs,  may  be  involved,  or  only  one  arm  and 
the  corresponding  leg.  The  disease  may  also  be  congenital.  This 
form  is  distinguished,  according  to  Gowers,  by  the  wide  separation  and 
irregular  movement  of  the  fingers  on  attempting  to  take  hold  of  an 
object.  From  pseudo-hypertrophic  paralysis  it  is  distinguished  by 
exaggeration  of  the  patellar  reflex,  absence  of  wasting,  and  presence 
of  clasp-knife  rigidity.  "  The  impairment  of  locomotion  gradually 
lessens  in  birth-palsy,  while  it  increases  in  pseudo-hypertrophic  par- 
alysis." 

The  prospect  of  the  disease  becoming  stationary  and  the  paralysis 
improving  is  better  in  the  infantile  form  than  in  adults.  As  a  rule, 
however,  arrest  of  the  disease  is  as  much  as  can  be  hoped  for.  It  is 
not  fatal  in  its  tendency. 

The  disease  is  distinguished  from  locomotor  ataxia  by  the  exaggera- 
tion of  reflexes  instead  of  their  abolition,  and  by  the  absence  of  eye- 
symptoms,  lightning-pains,  and  painful  crises.  Other  portions  than 
the  lateral  columns  of  the  cord  are  at  times  involved  and  give  rise  to 
disturbances  of  sensation  or  to  muscular  atrophy.  Hysterical  paral- 
ysis is  excluded  by  the  presence  in  spastic  paraplegia  of  spasmodic 
rigidity,  with  excessive  knee-jerk  and  ankle-clonus. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  879 

Ataxic  Paraplegia.  Ataxic  paraplegia,  or  lateral  and  posterior 
sclerosis,  presents  characteristics  of  both  locomotor  ataxia  and  spastic 
paraplegia.  The  prominent  symptoms  are  the  very  gradual  develop- 
ment of  motor  weakness  and  loss  of  coordinating  power.  The  weak- 
ness is  first  noticed  in  walking,  and  the  loss  of  coordination  at  night  or 
when  the  eyes  are  closed.  The  flexor  tendons  are  more  affected  than 
the  extensors.  The  weakness  and  lack  of  coordination  increase  gradu- 
ally until  the  gait  becomes  feeble  and  tottering,  and  finally  walking  is 
impossible  without  constant  support.  Up  to  this  point  the  disease 
resembles  locomotor  ataxia,  but  it  is  distinguished  from  it  by  the 
absence  of  lightning-pains  and  the  preservation  of  the  muscle-reflexes 
— indeed,  the  patellar  reflex  is  much  exaggerated,  and  ankle-clonus  is 
usually  present.  There  may  be  dull  pains  in  the  back  and  legs.  The 
arms  may  or  may  not  be  involved.  The  muscles  do  not  atrophy.  Eye- 
symptoms  are  usually,  not  always,  absent.  There  is  some  loss  of 
power  over  bladder  and  rectum,  but  it  does  not  amount  to  paralysis, 
nor  even  to  considerable  paresis. 

The  sexual  power  is  lost,  but  it  may  be  regained  for  a  time.  The 
tendency  of  the  disease  is  toward  a  condition  of  spastic  paraplegia,  the 
gait  of  which  has  already  been  described,  the  loss  of  coordination 
becoming  less  marked  as  the  paralysis  increases.  Cerebral  symptoms, 
beyond  loss  of  memory  and,  occasionally,  defect  in  speech,  are  absent. 

The  disease  runs  a  very  chronic  course,  and  is  not  fatal  in  itself. 
Death,  as  in  other  degenerations,  results  from  complications,  particularly 
kidney  disease  and  bedsores.  The  disease  is  distinguished  from  loco- 
motor ataxia  by  the  presence  of  the  patellar  tendon  reflex;  from  spastic 
'paraplegia  by  the  presence  of  incoordination ;  and  from  chronic  mye- 
litis by  the  absence  of  girdle-sensation. 

Hereditary  Ataxia.  Hereditary  ataxia,  Friedreich's  disease,  or 
hereditary  ataxic  paraplegia,  is  a  special  form  of  ataxia  which  differs 
in  the  following  important  particulars  from  the  ordinary  form.  It  is 
hereditary;  it  develops  most  frequently  in  childhood  and  at  the  age  of 
puberty;  it  attacks  males  and  females  with  about  equal  frequency; 
lightning-pains  are  absent,  and  there  is  greater  tendency  to  involve  the 
arms  and  to  affect  speech. 

The  disease  develops  gradually.  Incoordination,  first  of  the  legs 
and  then  of  the  arms,  is  the  most  obtrusive  symptom.  The  muscle- 
reflexes  are  abolished.  Nystagmus  is  the  most  constant  ocular  symp- 
tom. The  effect  upon  sensation  is  variable;  sometimes  it  is  impaired, 
and  at  others  it  is  entirely  normal. 

The  disease  is  very  chronic — from  ten  to  thirty  years.  Gowers  says 
the  only  guide  to  individual  prognosis  is  the  observed  rate  of  progress. 

Progressive  Muscular  Atrophy.  Progressive  muscular  atro- 
phy, wasting  palsy,  chronic  poliomyelitis,  or  amyotrophic  lateral  scle- 
rosis, is  due  to  a  combined  degeneration  of  the  multipolar  cells  in  the 
gray  matter  of  the  anterior  cornua,  and  of  the  pyramidal  tracts. 

The  disease  usually  attacks  an  arm  first,  and  either  the  hand-  or 
shoulder-muscles;  and  next  in  frequency,  a  leg.  Before  any  actual 
weakness  is  noticed  in  the  affected  member  there  may  be  a  feeling  of 
soreness  and  weariness  after  using  it.     Sometimes,  however,  wasting  is 


880  SPECIAL  DIAGNOSIS. 

the  first  thing  that  attracts  attention,  particularly  if  the  hand  is  affected 
first,  for  here  wasting  of  the  interossei  makes  a  characteristic  appear- 
ance. The  corresponding  leg  is  not,  as  a  rule,  noticeably  affected 
during  the  first  six  months.  The  atrophy  is  almost  always  steadily 
progressive,  involving  the  muscles  of  the  chest  aud  neck,  besides  those 
of  the  legs  and  arms.  Loss  of  power  accompanies  the  atrophy.  As 
a  rule  this  loss  is  most  marked  in  the  arms,  while  the  legs,  before  wasting 
becomes  pronounced,  are  in  the  condition  described  under  spastic  para- 
plegia. The  muscle-bundles  exhibit  fibrillary  twitchings  and  the 
atrophied  muscles  give  characteristic  degenerative  reactions. 

Respiration  is  much  embarrassed,  as  the  diaphragm  and  external 
respiratory  muscles  are  involved.  The  face  generally  escapes,  but 
speech  is  affected  by  the  extension  of  the  disease  to  the  medulla,  and 
glosso-labial  paralysis  is  simulated. 

Sensory  symptoms  rarely  amount  to  more  than  dull  pains,  except 
when  there  is  an  associated  meningitis.  The  sphincters  are  not  usually 
involved,  but  sexual  power  is  generally  lost.  In  advanced  cases  the 
affected  limbs,  especially  the  arms,  are  wasted  so  that  they  appear  like 
skin  stretched  over  bones. 

The  average  duration  of  the  disease  is  said  to  be  about  three  years, 
but  the  progress  may  be  more  or  less  rapid  in  individual  cases.  It  is 
rarely  arrested.  Gowers  says  that  wasting  which  has  existed  for  six 
months  will  probably  persist  unchanged.  The  chief  dangers  to  life 
are  pulmonary  complications  and  bulbar  paralysis. 

Pseudohypertrophic  Muscular  Paralysis.  Pseudo-hyper- 
trophic  muscular  paralysis  is  a  primary  disease  of  the  muscles,  consist- 
ing of  an  overgrowth  of  connective  tissue  and  subsequent  atrophy  of 
the  muscle.  The  disease  occurs  almost  always  in  childhood;  sometimes 
it  is  noticed  as  soon  as  the  child  begins  to  walk,  or  it  may  be  congen- 
ital. The  calf -muscles  are  first  involved,  and  hence  the  child  is  apt 
to  be  slow  in  learning  to  walk.  The  gastrocnemii  are  apparently  much 
enlarged,  though  this  enlargement  may  be  concealed  in  a  fat  child. 
It  stumbles  and  falls  in  attempting  to  run,  and  is  unable  to  raise  itself 
on  tiptoe.  The  calf-muscle  is  at  first  much  harder  than  normal,  and 
subsequently  becomes  softened  from  increase  of  lipomatous  tissue. 
Weakness  of  the  legs  may  be  recognized  for  months  or  even  years 
before  characteristic  changes  are  detected  in  the  muscles;  usually, 
however,  the  apparent  hypertrophy  can  be  noticed  within  a  few  weeks 
or  months  after  weakness  has  become  manifest.  Gradually  other  mus- 
cles become  affected,  the  infraspinatus  most  frequently.  Gowers 
attaches  great  diagnostic  importance  to  the  coexistence  of  enlargement 
of  the  infraspinatus  and  wasting  of  the  latissimus  and  lower  part  of 
the  pectoralis.  As  atrophy  and  accompanying  weakness  increase, 
change  of  position  is  effected  with  more  and  more  difficulty;  the  feet 
are  spread  wide  apart,  aud  the  gait  is  oscillating  ("  duck-like").  If 
prone  upon  the  ground,  the  child  raises  himself  first  upon  his  hands 
and  knees,  then  extends  the  knees  and  rests  upon  the  toes  and  hands, 
then  places  one  hand  upon  a  knee  with  the  other  remaining  upon  the 
ground,  and  then  pushes  himself  upright  from  this  position. 

Contractions  and  deformities  are  a  later  stage;  the  most  important. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  881 

are  club-foot  and  curvature  of  the  spine.  Sensation  and  the  muscles 
controlling  the  functions  of  the  bowel  and  bladder  are  unaffected. 
The  course  of  the  disease  is  slowly  progressive.  Gowers  states  that 
severe  pulmonary  disease  usually  ends  life  some  time  between  twelve 
and  twenty  years.  Few  patients  reach  the  age  of  forty  years.  The 
course  of  the  disease  is  slower  in  girls  than  in  boys. 

Simple  Idiopathic  Muscular  Atrophy.  Simple  idiopathic 
muscular  atrophy,  like  the  pseudo-hypertrophic  form,  occurs  in  fam- 
ilies, but  differs  from  it  in  the  fact  that  it  presents  no  apparent  hyper- 
trophy of  muscles,  and  that  the  palsy  involves  the  face,  occurs  at  a 
later  period,  and  affects  females  and  males  equally. 

The  disease  affects  persons  with  an  hereditary  tendency  to  it.  The 
type  of  Dejerine-Landouzy  occurs  in  early  childhood,  and  commences 
in  the  facial  muscles.  As  soon  as  the  atrophy  is  pronounced  the  facial 
expression  changes;  the  lower  lip  juts  forward,  the  lips  are  held  apart, 
and  the  labio-nasal  furrow  is  obliterated,  giving  the  face  a  dull  aud 
wondering  expression.  The  type  of  Erb  occurs  most  frequently  be- 
tween the  fifteenth  and  thirtieth  years,  but  may  appear  later.  Atrophy 
and  loss  of  power  go  hand-in-hand,  appearing  first,  usually,  in  the 
upper  arms,  legs,  or  in  the  face.  Unlike  progressive  muscular  atrophy, 
it  does  not  usually  attack  the  deltoids,  but  rather  the  biceps,  triceps, 
the  sterno-cleido-mastoid,  the  levator  anguli  scapula?,  the  supra-  and 
infra-spinatus,  the  small  muscles  of  the  hand,  or  the  muscles  of  the 
face.  Eventually  both  sides  are  involved,  though  the  disease  fre- 
quently begins  on  one  side.  The  shoulder-blades  are  prominent,  the 
thorax  flat  as  a  result  of  the  atrophy  of  the  pectorals,  and  the  gait 
waddling  because  the  gluteal  muscles  fail  to  hold  the  pelvis  firmly. 
In  rising  from  the  ground  the  movements  described  in  pseudo-muscular 
hypertrophy  are  repeated. 

In  the  lower  limbs  some  of  the  thigh-muscles  are  affected,  but  not 
the  calf-muscles.  The  diaphragm  may  also  be  involved.  The  mus- 
cles do  not  show  degenerative  reactions,  fibrillary  twitching  is  almost 
always  absent,  sensation  is  undisturbed,  the  functions  of  bladder  and 
rectum  remain  unaffected,  and  trophic  and  vasomotor  symptoms  are 
absent. 

There  is  no  uniformity  in  the  rate  of  progress  of  the  disease;  it 
may  reach  its  extreme  only  at  the  end  of  a  very  long  life,  or  in  a 
decade.  It  has  no  direct  tendency  to  kill.  Gowers  says  that  in  the 
cases  of  greatest  severity  and  rapid  course  the  patient  has  usually  died 
of  phthisis. 

The  neural  type  of  muscular  atrophy  (Charcot-Marie)  is  character- 
ized by  the  involvement,  first,  of  the  small  muscles  of  the  hands,  and 
feet,  and  then  slow  extension  upward.  The  muscles  atrophy,  show 
fibrillary  twitchings  and  give  the  reactions  of  degeneration.  In  the 
later  stages  the  fingers  and  toes  assume  the  claw  position,  and  pes 
equinus  may  develop.  In  a  variety  of  this  form  described  by  Dejerine 
and  Sollar  the  nerves  hypertrophy  and  can  be  felt  as  thick  cords. 

Thomsen's  Disease.  Thomsen's  disease  is  a  rare  congenital  and 
hereditary  affection,  characterized  by  tonic  spasm  of  the  muscles  when 
an  attempt  is  made  to  put  them  in  motion  after  a  period  of  rest.     If 

56 


882  SPECIAL  DIAGNOSIS. 

the  patient  persists  in  the  attempt,  the  spasm  gradually  lessens  until 
free  use  of  the  parts  can  be  obtained.  The  muscles  do  not  waste,  but 
exhibit  the  myotonic  reaction,  characterized  by  persistence  of  the  con- 
traction, and,  with  constant  currents,  rhythmic,  wave-like  contractions. 
ACC  is  often  as  great  as  CCC. 

Tumors  of  the  Spinal  Cord. 

Tumors  of  the  spinal  cord  may  be  syphilitic,  cancerous,  or  tubercular. 
The  prominent  symptoms  are  pain  and  gradually  developing  paralysis. 
The  character  of  the  pain  is  that  already  described  as  root-pain — dart- 
ing and  shooting;  it  is  paroxysmal,  very  severe,  sometimes  agonizing, 
making  life  a  burden.  Local  tenderness  is  not  marked,  and  may  be 
entirely  absent.  The  pains  often  begin  on  one  side,  and  finally  affect 
both.  Parsesthesise  and  anaesthesia?  are  also  present.  Muscular  spasm 
is  a  further  evidence  of  irritation  of  nerve-roots;  other  symptoms  are 
girdle-sensations,  paralysis,  atrophy,  and  contractures.  The  paralysis, 
like  the  root-pains,  is  often  at  first  unilateral,  but  usually  becomes 
bilateral  in  course  of  time.  It  begins  first  as  a  paresis  and  only 
gradually  deepens  into  paralysis. 

The  superficial  and  deep  reflexes  are  sometimes  decidedly  increased. 
The  two  sides  may  exhibit  a  difference  in  temperature. 

The  diagnosis  of  the  seat  of  the  tumor  must  be  made  by  noting  the 
level  at  which  the  cord-functions  are  disturbed.  Tumors  of  the  cord, 
as  distinguished  from  those  of  the  membranes  pressing  upon  or  extend- 
ing into  the  cord,  are  characterized  by  a  relative  prominence  of  paral- 
ysis and  absence  of  root-symptoms.  It  should  be  remembered  that 
a  secondary  myelitis  may  be  produced.  If  the  lumbar  enlargement  is 
involved,  or  the  cauda,  reflex  action  is  abolished;  whereas  if  the  growth 
is  situated  in  the  dorsal  region,  or  still  higher  up,  reflex  action  is  exag- 
gerated; again,  in  tumors  of  the  lumbar  enlargement  and  cauda  the 
legs  atrophy.  Tumors  of  the  cervical  region  cause  pain  and  often 
atrophy  in  the  arms,  while  the  legs  show  excessive  reflex  action.  There 
may  also  be  interference  with  respiration. 

Syringomyelia. 

Syringomyelia  is  a  progressive,  chronic  affection,  characterized  path- 
ologically by  the  destruction  of  a  portion  of  the  spinal  cord  and  the 
formation  of  cavities.  The  symptoms  are  muscular  atrophies,  trophic 
lesions,  disassociation  of  the  cutaneous  sensations,  temperature-  and 
pain-sense  being  lost,  while  tactile  sense  either  persists  or  is  but  slightly 
impaired.  Trophic  changes  are  very  frequent,  and  usually  take  the 
form  of  painless  panarites,  ulcerations  or  blisters  of  the  skin,  and  some- 
times dry  arthritis.  If,  as  is  usually  the  case,  the  cavity  is  in  the  tho- 
racic region,  the  arms  show  the  degenerative  changes,  and  the  legs 
exhibit  spastic  phenomena,  and  there  is  interference  with  the  functions 
of  the  bladder  and  rectum.     The  prognosis  is  hopeless. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  883 


Diseases  of  the  Brain.     Pachymeningitis. 

Inflammation  of  the  dura  mater  usually  develops  secondarily  to 
disease  of  adjacent  structures,  or  to  injury;  its  symptoms  are  to  be 
picked  out  from  those  of  the  primary  condition.  They  are  chiefly 
headache,  fever,  delirium,  and  perhaps  convulsions.  Fever  is  not  a 
constant  symptom.  If  the  inflammatory  products  press  upon  the  cor- 
tical motor  area,  there  may  be  paralysis  of  the  opposite  limbs. 

, Leptomeningitis. 

Inflammation  of  the  pia  and  arachnoid  may  be  acute  or  chronic;  it 
may  be  simple,  tubercular,  syphilitic,  or  epidemic  (see  Cerebro-spinal 
Fever);  it  may  be  confined  to  the  cortex  or  base,  or  may  be  general. 

1.  Acute  Meningitis  is  characterized  by  more  or  less  sudden  onset 
of  headache,  vomiting,  delirium,  and  couvulsions,  accompanied  by 
stiffness  of  certain  muscles,  especially  of  the  muscles  of  the  back  of 
the  neck,  and,  later,  by  paralysis  and  coma. 

Headache  is  the  most  prominent  symptom.  It  is  most  frequently 
frontal,  but  may,  in  rare  instances,  be  general;  it  is  usually  intense, 
and  in  paroxysms  the  headache  becomes  of  maddening  intensity,  caus- 
ing the  patient  to  shriek  with  pain.  It  is  aggravated  by  light,  and 
by  sound  or  other  vibration.  Rarely,  headache  is  absent;  when  this 
is  the  case  the  meningitis  is  most  frequently  secondary  to  septic  or 
blood  diseases. 

Vomiting  is  sudden  and  explosive,  without  antecedent  or  subsequent 
nausea,  or  any  local  cause  except  the  presence  of  food. 

Delirium  is  usually  active  in  type,  and  may  be  mild,  or  almost 
maniacal.  It  is  not  often  continuous,  but  is  broken  by  lucid  intervals. 
Coma  sometimes  follows  delirium. 

Rigidity  of  the  muscles  of  the  back  of  the  neck,  in  marked  cases 
accompanied  by  retraction  of  the  head,  is  an  important  symptom. 
Convulsions,  when  they  occur,  are  general.  They  are  more  likely  to 
occur  in  children  than  in  adults.  They  may  also  be  partial  or  unilat- 
eral, and  so  may  paralyses.  Cutaneous  hyperesthesia  is  not  very 
uncommon.  Neuritis  of  the  optic  nerve,  according  to  Gowers,  is  a 
common  symptom  in  meningitis  of  the  base,  but  is  rare  when  the 
inflammation  is  confined  to  the  convexity.  The  most  constant  and 
important  eye-symptoms  are  strabismus  and  inequality  of  the  pupils. 
The  facial  nerve  may  be  affected,  especially  in  meningitis  of  the  base. 
The  range  of  temperature  is  far  from  uniform.  Usually  there  is  mod- 
erate fever  from  the  start.  Sometimes,  especially  in  purulent  cases, 
the  fever  is  high  and  remains  so  until  the  patient's  death.  In  fatal 
cases  the  temperature  may  either  rise  or  fall  on  the  approach  of  death, 
and  in  rare  cases  it  may  remain  normal  throughout.  The  pulse  is  not 
characteristic. 

The  disease  lasts  from  one  or  two  days  to  two  or  three  weeks. 

The  symptoms  vary  somewhat  according  to  the  character  of  the 
inflammation.     In  simple  meningitis  the  fever  is  more  marked,  optic 


884  SPECIAL  DIAGNOSIS. 

neuritis  is  more  common,  and  the  duration  is  longer.     Recovery  may 
ensue. 

Tubercular  Meningitis  is  preceded  by  deterioration  of  the  gen- 
eral health,  emaciation,  slight  evening  fever,  peevishness,  and,  some- 
times, distinct  evidence  of  tubercle  elsewhere,  particularly  in  the  lungs. 
Headache  and  apparently  causeless  vomiting  are  important  symptoms; 
they  may  appear  first  at  the  onset  of  the  disease,  or  may  precede  it  by 
a  short  time.  Other  early  symptoms  are  constipation,  nightmare,  irreg- 
ular pulse,  and  cerebral  hyperesthesia,  as  the  result  of  which  light 
becomes  painful,  and  slight  sounds  are  disturbing.  Loss  of  flesh  con- 
tinues, there  is  moderate  fever,  the  abdomen  becomes  retracted,  the 
child  loses  strength,  becomes  apathetic,  lying  with  its  eyes  partly  open. 
It  may  be  roused  to  temporary  interest  in  its  accustomed  playthings, 
but  soon  turns  from  them  in  anger  or  disgust.  Bright-red  spots  or 
streaks  of  hyperemia  may  appear  and  disappear  rapidly  in  the  face.  If 
the  thumb-nail  be  pressed  upon  the  skin  and  drawn  across  it,  a  red 
streak  follows — tache  meningeale. 

The  child's  sleep  is  disturbed  by  dreams,  and  it  utters  a  peculiar, 
piercing  cry,  the  u  hydrocephalic  cry." 

There  may  be  some  rigidity  of  the  muscles  of  the  back  of  the  neck. 
Gowers  lays  particular  stress  upon  the  occurrence  of  aphasia.  The 
eye-symptoms  are  strabismus,  irregularity  of  pupils,  and  optic  neuritis. 

Delirium  and  convulsions  may  occur  early,  but  usually  not  until  the 
second  week.  Local  convulsions  and  corresponding  palsies  are  com- 
mon, but  the  palsy  may  be  transient.  Death  may  occur  in  convulsion, 
or  more  commonly  in  coma. 

The  temperature-range  is  not  constant,  and  often  fluctuates  consider- 
ably within  short  intervals.  Sometimes  the  pulse  is  frequent  at  first, 
then  becomes  slow  and  irregular,  and  again  very  frequent.  The  respi- 
ration is  irregular  and  cerebral  in  type  toward  the  close  of  the  disease. 
The  duration  of  the  disease  is  usually  from  one  to  three  weeks,  but  it 
may  be  prolonged  to  twice  that  time.  The  prognosis  is  not  necessarily 
fatal,  but  most  patients  die.  The  prognosis  is  graver  when  convul- 
sions or  coma  appear  early,  and  is  better  the  longer  coma  is  deferred. 

Meningitis  is  to  be  distinguished  from  general  febrile  diseases  with 
cerebral  symptoms.  Headache  is  common  in  the  latter,  but  it  is  rarely 
so  intense  as  in  meningitis,  unless  there  be  at  the  time  high  fever. 
Delirium  is  also  common  in  both,  but  it  succeeds  the  headache  in 
febrile  diseases,  whereas  in  meningitis  both  symptoms  persist  together. 
Convulsions  may  occur  at  the  onset  of  the  exanthemata  and  of  pneu- 
monia, but  in  meningitis  they  are  a  later  symptom.  Eye-symptoms 
are  absent  in  general  febrile  diseases.  The  best  safeguard  against  a 
mistake  in  diagnosis  is  to  examine  every  organ  carefully  before  con- 
cluding that  the  mischief  is  in  the  brain-membranes;  the  lungs  espe- 
cially should  be  examined  for  pneumonia,  and  the  spleen  and  bowels 
for  signs  of  typhoid  fever.  Tubercular  meningitis  is  generally  sec- 
ondary, but  it  is  not  often  possible  to  detect  the  primary  focus. 

Tubercular  meningitis  is  distinguished  from  the  simple  form  by  the 
occurrence  of  premonitory  symptoms  of  failing  health  in  a  child  dis- 
posed by  heredity  to  tuberculosis,  or  affected  by  an  antecedent  tuber- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  885 

culosis  of  bone,  gland,  or  lung.  It  is  further  distinguished  by  the 
absence  of  other  causes  of  meningitis,  particularly  traumatism,  sup- 
purative disease  of  the  middle  ear,  infectious  disease,  such  as  ery- 
sipelas, or  septicaemia.  Moreover,  the  individual  symptoms  are 
important :  tubercular  meningitis  is  generally  basilar;  hence,  appar- 
ently causeless  vomiting,  strabismus,  irregularity  of  pupils,  and  optic 
neuritis  are  very  significant  symptoms.  The  pulse  in  tubercular  men- 
ingitis is  often  at  first  frequent,  then  becomes  slow — 40  to  60 — and 
irregular  and  intermittent  in  the  first  stage,  subsequently  becoming 
frequent  and  irregular,  and  finally  very  frequent,  but  regular.  The 
respiration  is  irregular  and  sighing,  and  may  be  of  the  Cheyne-Stokes 
type.  The  temperature,  also,  has  a  lower  range  and  is  more  fluctuat- 
ing than  in  simple  meningitis.  Gowers  says  that  tubercular  meningitis 
is  one  of  the  most  common  causes  of  aphasia  in  children,  and  that  the 
aphasia  is  sometimes  an  early  symptom.  It  is,  however,  difficult  to 
detect  it  in  children  of  the  age  at  which  tubercular  meningitis  is  most 
common.  On  the  whole,  the  disease  is  more  liable  to  be  suspected 
when  it  does  not  exist  than  to  be  overlooked  when  present. 

In  adults  tubercular  meningitis  is  rare  and  is  always  secondary,  gen- 
erally to  disease  of  the  lungs.  It  is,  therefore,  a  late  manifestation  of 
the  disease,  except  in  the  cases  in  which  there  is  a  general  miliary 
tuberculosis. 

Chronic  Meningitis.  Chronic  meningitis  is  usually  alcoholic  or 
syphilitic,  but  it  may  be  the  result  of  sunstroke.  The  alcoholic  form 
involves  principally  the  convexity,  and  is  characterized  by  headache, 
some  loss  of  intellectual  power,  perhaps  irritability  of  temper;  there 
may  also  be  occasional  delirium  and  some  optic  neuritis. 

In  the  syphilitic,  form  the  meningitis  is  more  likely  to  be  local,  and 
usually  extends  from  the  seat  of  a  gumma.  The  symptoms,  therefore, 
are  apt  to  be  focal.  Gowers  says  that  it  is  highly  probable  that  focal 
inflammation  in  adults  is  always  syphilitic  in  nature;  the  traumatic 
form,  of  course,  is  excepted. 

The  purulent  form  of  acute  meningitis  most  frequently  affects  the 
membranes  of  the  convexity.  It  is  characterized  by  high  fever,  with  or 
without  rigors,  intense  headache,  vomiting,  motor  symptoms,  possibly 
amounting  to  convulsions,  and  coma. 

It  may  arise  from  mastoid  disease,  from  injury,  or  may  be  part  of 
a  general  septic  process.     Its  course  is  rapidly  fatal,  as  a  rule. 

Diagnosis.  Meningitis  is  simulated  by  brain-tumor.  Loss  of  motor 
power  in  the  limbs  indicates  tumor  rather  than  meningitis.  Gowers 
says  that  if,  after  the  first  two  weeks  from  the  beginning  of  the  dis- 
ease, optic  neuritis  continues  to  increase,  and  the  patient  does  not 
become  comatose,  the  diagnosis  of  tumor  is  almost  certain. 

The  most  important  symptom  in  differential  diagnosis  of  meningitis 
from  hysteria  is  increased  temperature.  "When  strabismus  is  present 
in  hysteria  it  is  convergent,  never  divergent.  Gowers  asserts  that 
divergent  strabismus  or  irregularity  of  pupil,  whether  transient  or 
permanent,  is  certain  evidence  of  organic  disease.  In  hysteria,  also, 
there  may  be  retention  of  urine,  but  never  incontinence. 


886  SPECIAL  DIAGNOSIS. 


Cerebral  Anaemia. 


Cerebral  ansernia  may  be  a  part  of  the  general  anseinia  which  char- 
acterizes chlorosis,  leucocythsemia,  and  many  other  affections;  or  it  may 
result  from  hemorrhage  or  other  exhausting  discharge.  In  other  cases 
it  is  local,  resulting  from  a  deficiency  in  the  supply  of  blood  to  the 
brain.  Such  ausernia  occurs  in  arterio-sclerosis,  in  aortic  valvular  dis- 
eases, and  in  aneurism  of  the  aorta  and  its  cervical  branches. 

If  anaemia  is  suddenly  developed,  as  from  hemorrhage  or  a  sudden 
assumption  of  the  erect  posture  by  a  person  with  feeble  circulation, 
the  phenomena  are  those  of  faintness,  ringing  in  the  ears,  dizziness, 
partial  or  complete  blindness,  general  muscular  relaxation,  nausea, 
frequent,  feeble  pulse,  and  shallow,  sighing  respiration.  The  skin 
may  become  cold  and  be  bathed  in  perspiration.  The  symptoms  are 
aggravated  by  the  erect  posture. 

When  ansemia  develops  gradually  the  symptoms  are  less  intense. 
Intellection  is  performed  with  slowness  and  difficulty,  slight  effort  causes 
weariness  and  headache,  and  the  patient  is  drowsy.  Sight  and  hearing 
may  be  defective,  and  musca?  volitantes  and  tinnitus  are  common  causes 
of  complaint.     There  is  usually  some  muscular  weakness. 

The  diagnosis  is  not  difficult. 

Hypersemia  of  the  Brain. 

Hyperemia  of  the  brain  may  be  active  or  'passive. 

The  diagnosis  of  active  congestion  is  more  liable  to  be  suspected  when 
it  is  not  present  than  overlooked  when  present.  The  most  trustworthy 
symptoms,  according  to  Gowers,  are  the  paroxysmal  recurrence  of 
headache,  delirium,  and  sometimes  fever,  preceded  by  throbbing  of  the 
vessels  and  reddening  of  the  face.  The  probability  of  active  conges- 
tion is  increased  if  the  symptoms  are  relieved  by  nose-bleed  or  vene- 
section. 

The  diagnosis  of  passive  congestion  is  based  upon  signs  of  a  plethoric 
habit,  such  as  florid  complexion,  turgid  vessels,  associated  with  a  dull, 
more  or  less  persistent  headache,  which  is  aggravated  by  stooping,  by 
coughing,  constipation,  or  by  the  recumbent  posture.  Other  symptoms 
are  flashes  of  light  before  the  eyes,  slight  dizziness,  sluggish  intellect 
with  drowsiness,  and  some  hyperesthesia  of  the  extremities.  Slight 
convulsions  sometimes  occur.  Passive  congestion  occurs  in  conditions 
which  retard  the  escape  of  blood  from  the  brain. 

Cerebral  Hemorrhage.     (Apoplexy.) 

Cerebral  hemorrhage — that  is  to  say,  hemorrhage  into  the  brain-sub- 
stance— is  caused,  apart  from  traumatism^  by  the  rupture  of  a  blood- 
vessel the  walls  of  which  have  been  weakened  by  disease  and  have 
become  the  seat  of  minute,  or  miliary,  aneurisms. 

The  liability  to  it  increases  very  markedly  after  the  fortieth  year.  The 
symptoms  differ  considerably  according  to  the  extent  of  the  hemorrhage 
and  its  seat,  but  the  most  frequent  and  prominent  are:  sudden  onset 


DISEASES  OF  THE  NERVOUS  SYSTEM.  887 

with  loss  of  consciousness,  convulsions  and  coma,  and,  if  recovery 
result,  hemiplegia  on  the  side  opposite  the  lesion. 

Premonitory  symptoms  are  present  in  a  few  cases.  These  may  be 
those  of  cerebral  congestion  (q.  v.)  or  consist  of  vertigo,  vomiting,  or 
change  of  temper.  In  some  cases  an  unusual  sense  of  well-being  has 
preceded  an  attack.  It  is  probable  that  these  symptoms  are  really  due 
to  minute  hemorrhages.  The  onset  may  be  very  abrupt,  the  patient 
falling  unconscious  as  though  struck  upon  the  head.  More  frequently 
the  loss  of  consciousness,  while  sudden,  is  preceded  by  headache,  gid- 
diness, faintness,  nausea,  or  difficulty  in  articulation.  If  the  seizure 
occurs  after  a  hearty  meal,  the  patient  usually  vomits  freely  and  then 
becomes  unconscious,  with  conjugate  deviation  of  the  pupils,  the  face 
drawn  to  one  side,  the  cheeks  flapping  with  stertorous  respiration,  the 
lips  covered  with  froth,  and  the  arm  and  leg  upon  the  affected  side 
alternately  convulsed  and  rigid,  and  relaxed. 

If  the  attack  comes  on  when  the  patient  is  standing,  a  weakness  in 
one  leg  may  cause  him  to  fall  or  sit  down,  unconsciousness  soon  devel- 
oping. 

The  degree  of  consciousness  varies  with  the  severity  of  the  case. 
Usually  it  is  completely  lost,  but  it  may  be  soon  regained.  Convul- 
sions are  most  frequent  when  the  hemorrhage  is  cortical.  The  pulse 
is  usually  slow  and  full,  but  it  may  be  small,  hard,  and  frequent.  The 
respiration  is  stertorous,  aud  may  be  Cheyne-Stokes.  When  convul- 
sions are  present,  they  usually  begin  by  twitching  of  the  eyelids  and 
eyebrows,  rotation  of  the  head  and  eyes,  by  successive  small  move- 
ments to  one  side,  usually  the  side  of  the  brain-lesion,  aud  then  the 
convulsiou  extends  to  the  arm  and  leg,  and  may  become  general.  If 
consciousness  is  not  completely  lost,  the  hemiplegia  becomes  very  con- 
spicuous; or,  if  the  seizure  has  occurred  during  sleep,  the  patient  him- 
self may  first  become  aware  of  it  by  the  presence  of  hemiplegia  when 
he  attempts  to  get  out  of  bed.  When  unconsciousness  is  profound 
(coma)  urine  and  fasces  may  be  passed  unconsciously.  In  some  cases 
there  is  an  apparently  mild  seizure  with  rapid  return  of  consciousness 
aud  power,  except,  perhaps,  of  speech,  but  in  a  few  days  the  symptoms 
become  worse  aud  the  patient  dies  comatose.  The  name  ingravescent 
apoplexy  has  been  applied  to  such  cases. 

If  consciousness  is  regained  aud  the  patient  recovers,  the  symptoms 
are  those  of  palsy.  This  is  most  complete  at  first.  Except  in  rare 
cases,  recovery  is  only  partial.  The  extent  aud  distribution  of  the 
palsy  depend  upon  the  seat  of  the  lesion.  It  is  almost  always  unilat- 
eral. 

The  seat  of  the  hemorrhage  can  be  judged  with  tolerable  accuracy. 
The  most  common  seat  is  in  the  neighborhood  of  the  corpus  striatum 
aud  internal  capsule,  hence  the  frequency  of  hemiplegia.  Cortical 
hemorrhage  is  rare.  It  is  characterized  by  local  convulsions,  aud  the 
resulting  palsy  may  affect  only  a  leg  or  an  arm.  A  large  hemorrhage 
into  the  pons  causes  deep  coma,  general  paralysis,  and  convulsions 
which  are  usually  general,  but  sometimes  involve  only  the  legs.  The 
pupils  are  contracted,  there  may  be  general  aruesthesia,  vomiting  is 
common,   and  there  is  often  high  temperature.     Death  often  occurs 


SPECIAL  DIAGNOSIS. 

early.  Hemorrhage  into  the  optic  thalamus  causes  a  decided  rise  in 
temperature,  but  the  palsy  is  slight,  and  there  is  usually  permanent 
hemianopia. 

Hemorrhage  into  the  medulla  causes  death  speedily,  without  the 
occurrence  of  convulsions,  but  with  high  temperature. 

Hemorrhage  into  the  cerebellum  may  or  may  not  cause  paralysis,  and, 
when  it  does,  the  paralysis  may  be  on  the  same  side  or  on  the  side  oppo- 
site the  lesion.  It  is  attended  by  loss  of  consciousness  and  repeated 
vomiting,  but  vision  is  not  affected. 

Hemorrhage  into  the  ventricles  is  marked  by  profound  loss  of  con- 
sciousness, with  conjugate  deviation  of  the  head  and  eyes.  There  may 
be  temporary  improvement,  followed  by  complete  coma  with  or  without 
convulsions. 

Meningeal  hemorrhage  is  usually  of  traumatic  origin.  If  the  blood 
is  poured  out  suddenly,  the  symptoms  are  those  of  severe  apoplexy, 
with  rapid  development  of  coma.  If  the  escape  of  blood  is  more 
gradual,  there  is  often  a  period  during  which  the  patient  is  able  to 
walk  about;  drowsiness  then  comes  on,  and  deepens  into  coma.  Less 
commonly  there  are  convulsions,  and,  sometimes,  delirium. 

Diagnosis.  The  coma  of  apoplexy  is  distinguished  from  that  of 
alcoholism  by  the  drawn  appearance  of  the  face,  and  by  more  profound 
unconsciousness.  Frequently  the  alcoholic  patient  can  be  roused  suffi- 
ciently to  grunt  his  disapproval  or  to  turn  over.  The  fumes  of  am- 
monia are  said  to  rouse  him.  The  temperature  in  alcoholic  coma  is 
depressed.  The  absence  of  convulsions  is  in  favor  of  alcoholism. 
The  respiration  in  the  latter  is  quieter,  aud  is  not  attended  by  frothing 
at  the  mouth  or  flapping  of  the  cheeks.  Mistakes  are  most  likely  to 
occur  when  no  history  of  the  patient's  previous  condition  or  of  the 
mode  of  onset  of  the  coma  can  be  obtained.  The  odor  of  alcohol  upon 
the  breath  is  of  value  if  the  patient  is  known  to  be  intemperate,  and 
if  no  one  has  administered  alcohol  after  the  coma.  Incontinence  of 
urine  or  of  faeces  is  against  alcoholism,  and  so  is  a  bitten  tongue. 

Apoplexy  is  distinguished  from  urcemia  by  its  sudden  onset  and  by 
the  comparative  or  complete  absence  of  premonitory  symptoms.  In 
uraemia  the  patient  has  generally  suffered  from  headache  and  morning 
nausea,  which  may  be  called  by  him  "  bilious  attacks."  The  pulse  is 
often  of  markedly  high  tension,  and  the  second  aortic  sound  is  accent- 
uated. In  other  cases  there  will  be  found  oederna  of  the  eyelids,  a 
pale,  waxy,  bloated  face,  sometimes  dropsy,  and  failure  of  vision. 
Marked  drowsiness  often  immediately  precedes  an  attack,  and  it  is 
frequently  accompanied  by  cramps  and  twitchings  of  the  muscles. 
The  coma  of  uraemia  is  accompanied  by  stertorous  respiratiou  and 
frothing  at  the  mouth;  but  the  cheeks  do  not  flap  during  respiration, 
and  the  face  is  not  drawn  as  in  apoplexy.  The  convulsions  of  apoplexy 
are  more  likely  to  be  unilateral  than  those  of  uraemia,  which  are  epi- 
leptic in  type.  They  are  often  accompanied  in  apoplexy  by  conjugate 
deviation  of  head  and  eyes,  conditions  that  are  rare  in  uraemia.  More- 
over, in  apoplexy  the  skin  is  moist  and  warm,  whereas  in  uraemia  it 
is  cool,  dry,  and  harsh.  The  temperature  in  apoplexy  may  be  elevated 
at  first,  and  then  depressed;  or  it  may  contiuue  to  rise.      In  uraemia  it 


DISEASES  OF  THE  NERVOUS  SYSTEM.  889 

sometimes  is  depressed  and  sometimes  elevated.  The  condition  of  the 
urine  is  important  in  diagnosis,  but  it  is  not  an  infallible  guide.  A 
scanty,  reddish,  opaque  urine,  containing  a  large  amouut  of  blood  and 
albumin,  certainly  points  to  uraemia;  but  apoplexy  often  occurs  in  a 
person  who  has  unsound  kidneys,  and  its  onset  is  frequently  attended 
with  the  appearance  of  considerable  albumin  and  of  casts  in  the  urine. 

Cerebral  hemorrhage  is  to  be  distinguished  from  softening,  the  result 
of  embolism,  by  the  age  of  the  patient,  the  presence  or  absence  of  a 
cause  of  embolism,  such  as  valvular  heart  disease  and  syphilis,  and  the 
intensity  of  the  symptoms.  Embolism  is  more  frequent  in  those  under 
forty  years;  cerebral  hemorrhage  in  those  over  forty  years.  When, 
however,  the  patient  is  past  middle  life  the  probability  of  softening 
does  not  dimiuish,  and  the  diagnosis  from  hemorrhage  must  be  made 
by  the  symptoms  and  the  patient's  condition.  Intensity  of  apoplectic 
symptoms  and  persistent  palsy  are  in  favor  of  hemorrhage.  A  high- 
tension  pulse,  hypertrophy  of  the  left  ventricle,  and  atheroma  of  the 
arteries  of  the  limbs  are  in  favor  of  hemorrhage;  on  the  other  hand, 
a  weak  heart  and  feeble  pulse  favor  softening.  If  the  attack  comes 
on  after  much  excitement  or  strong  muscular  effort,  it  is  in  favor  of 
hemorrhage. 

Premonitory  symptoms,  such  as  singing  in  the  ears  or  paresthesia 
of  one  side,  are  in  favor  of  softening.  Profound  coma  and  violent 
convulsions  are  probably  due  to  hemorrhage. 

Cerebral  thrombosis  is  characterized  by  more  gradual  onset,  shorter 
duration  of  paralysis  and  other  symptoms,  and  by  more  complete 
recovery. 

Thrombosis  of  the  Superior  Longitudinal  Sinus. 

This  occurs  most  frequently  in  children;  it  may  arise  spontaneously 
in  the  course  of  acute  diseases  producing  great  prostration,  especially 
entero-colitis.  It  results  also,  and  more  frequently,  from  inflammatory 
disease  of  the  brain-membranes  or  bone  adjacent  to  the  sinus,  and  exten- 
sion of  the  inflammation  to  the  walls  of  the  sinus.  The  symptoms 
are  the  gradual  development  of  coma  with  convulsions,  which  may  be 
general  or  unilateral.  Headache,  strabismus,  and  more  or  less  rigidity 
of  the  limbs  are  common.  Adults  are  more  likely  to  be  affected  with. 
delirium  than  with  convulsions.  Epistaxis  may  occur,  and  sometimes 
there  is  oedema  with  distended  veins  upon  the  scalp  and  forehead.  The 
result  is  fatal  in  nearly  all  cases,  but  recovery  is  possible  in  sponta- 
neous thrombosis. 

Infantile  Hemiplegia. 

Infantile  hemiplegia  is  an  acute  cerebral  palsy  occurring  duringthe 
first  five  years  of  life;  it  is  either  primary  or  secondary  to  acute  dis- 
eases, particularly  scarlet  fever  and  measles.  The  onset  of  the  disease 
may  be  marked  by  vomiting  and  convulsions,  by  drowsiness  or  coma, 
or  the  child  may  wake  up  in  the  morning  with  well-marked  hemiplegia. 
In  other  cases  a  series  of  convulsions  precedes  the  appearance  of  the 
palsy,  and,  in  still  other  cases,  the  onset  is  marked  by  fever.   The  initial 


890  SPECIAL  DIAGNOSIS. 

convulsions  may  be  general,  but  more  frequently  they  are  unilateral; 
when  the  left  hemisphere  is  the  seat  of  the  lesion,  aphasia  may  be  a 
symptom,  and  it  is  one  of  the  slowest  to  disappear.  The  duration  of 
the  palsy  is  variable;  sometimes  recovery  is  very  prompt,  occurring  in 
a  few  days;  in  other  cases  several  months  may  elapse;  and,  in  still 
others,  the  paralysis  may  be  permanent.  It  is  always  most  intense 
and  widespread  at  first,  and  then  slowly  disappears,  the  leg  usually 
showing  its  effect  longest.  The  palsy,  as  indicated  by  the  name  of  the 
disease,  is  a  hemiplegia;  in  rare  cases  it  is  bilateral,  due  to  a  bilateral 
brain-lesion.  The  affected  limbs  are  at  first  limp  and  flaccid;  as  power 
returns  contractures  begin,  and  eventually  there  may  be  some  spasm, 
with  or  without  clonic  movements.  As  the  opposite  side  grows,  the 
portions  permanently  paralyzed  become  shortened  and  somewhat  wasted. 
Sensation  is  unimpaired.  The  mind  is  usually  defective  when  palsy  is 
permanent,  and  idiocy  and  epilepsy  are  not  infrequent  sequences.  The 
prognosis  is  good  as  regards  life,  but  guarded  as  to  the  degree  and 
duration  of  subsequent  paralysis.  Repeated  convulsions  render  the 
prognosis  grave.  The  rapidity  with  which  consciousness  is  regained 
and  the  palsy  begins  to  disappear  is  an  index  of  the  rapidity  and  com- 
pleteness of  recovery. 

Acute  Softening- 
Acute  softening  of  the  brain  is  the  result  of  embolism  or  throm- 
bosis. The  most  common  cause  of  embolism  is  a  recent  endocarditis 
with  vegetation  upon  the  valves.  Thrombosis  occurs  in  atheroma  and 
in  syphilitic  inflammation  of  the  cerebral  arteries.  It  may  also  occur 
in  general  diseases,  acute  or  chronic,  which  produce  systemic  weakness 
or  weakness  of  the  heart. 

The  symptoms  resemble  more  or  less  closely  those  of  cerebral  hem- 
orrhage. 

Embolism  is  to  be  distinguished  by  the  age  of  the  patient ;  it  is  most 
common  from  adolescence  to  middle  life,  whereas  hemorrhage  is  more 
common  after  middle  life.  The  onset  is  sudden  and  apoplectic  in  char- 
acter. It  is  marked  by  coma  and  convulsions,  but  loss  of  conscious- 
ness is  not  usually  so  profound  or  of  such  long  duration,  as  in  hemor- 
rhage. This,  however,  depends  somewhat  upon  the  size  of  the  vessel 
plugged. 

Thrombosis  differs  from  both  hemorrhage  and  embolism  in  being 
more  gradual  in  onset.  Premonitory  symptoms,  consisting  of  head- 
ache, dizziness,  and  paresthesia,  are  common.  Consciousness  may  or 
may  not  be  lost,  depending  upon  the  size  of  the  occluded  vessel  and 
consequent  area  of  softening.  Delirium  may  follow  the  primary  loss 
of  consciousness,  particularly  in  atheromatous  softening.  A  secondary 
rise  of  temperature  is  more  common  in  softening  than  in  hemorrhage, 
and  it  may  amount  to  hyperpyrexia. 

Aphasia,  monoplegia,  and  recurring  convulsions  are,  according  to 
Gowers,  more  common  in  softeuing  than  in  hemorrhage ;  and  in  the 
subsequent  chronic  stage,  disorders  of  movement,  mental  failure,  and 
emotional  mobility  as  well  as  entire  absence  of  focal  symptoms  are 
somewhat  more  common  in  softening;. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  891 

Abscess  of  the  Brain. 

Abscess  of  the  brain  is  most  frequently  the  result  of  chronic  suppu- 
rative otitis  media,  and  in  such  cases  the  symptoms  of  mastoid  disease 
usually  precede  it.  It  may  also  be  the  result  of  injury  or  disease  of 
the  cranial  bones,  or  be  part  of  a  septic  process.  It  is  most  common 
in  male  adults  between  the  tenth  and  thirtieth  years. 

The  most  important  consideration  in  diagnosis  is  the  existence  or 
antecedence  of  a  cause  of  abscess,  in  association  with  inflammatory 
cerebral  symptoms. 

The  symptoms  of  brain-abscess  depend  upon  the  character  of  the 
pus  and  the  seat  of  the  abscess;  in  some  cases,  particularly  when  the 
cause  is  traumatic,  the  symptoms  are  inflammatory  and  the  case  pro- 
gresses rapidly  to  a  fatal  issue  in  a  few  weeks;  in  others,  after  a  period 
of  indefinite  cerebral  symptoms,  the  abscess  becomes  latent;  and,  in 
still  other  cases,  particularly  when  there  is  a  general  disease,  the  cere- 
bral mischief  may  be  obscured. 

The  symptoms  in  abscess  that  runs  a  rapid  course  are  those  of  men- 
ingitis, rarely  associated  with  focal  symptoms.  In  the  early  stage 
delirium,  convulsions,  and  coma  are  uncommon;  but  coma,  at  least, 
appears  later,  and  may  be  preceded  by  rigors.  In  these  cases,  how- 
ever, the  cause  is  most  frequently  injury  or  septicaemia,  whereas  in 
the  great  majority  of  cases,  which  are  the  result  of  ear  disease,  the 
abscess,  during  its  formative  stage,  gives  rise  to  no  symptoms  except 
headache  and  disordered  or  weakened  intellect,  and  may  remain  latent 
for  months  or  even  years.  The  symptoms  may  develop  very  gradu- 
ally, but  more  commonly  end  abruptly,  and  symptoms  of  cerebritis 
and  meningitis,  occasionally  with  focal  symptoms  due  to  tumor,  appear. 
The  most  important  symptoms  are  fever,  vomiting,  headache,  convul- 
sions, paralysis,  optic  neuritis,  and  coma.  The  headache  is  persistent, 
and  is  often  worse  at  the  seat  of  disease.  Vomiting  is  associated  with 
constipation,  fever,  and  sometimes  with  rigors  and  sweats.  Convul- 
sions are  usually  general,  and  are  accompanied  by  paralysis,  most  fre- 
quently a  hemiplegia.  Rigidity  in  the  neck  and  retraction  of  the  head 
are  not  usually  present  except  when  there  is  an  associated  basilar 
meningitis.  Optic  neuritis,  according  to  Gowers,  is  less  common  than 
in  tumor,  but  more  common  than  statistics  would  indicate.  Delirium 
and  coma  usually  close  the  scene. 

Wheu  the  abscess  rues  an  acute  course,  and  there  has  been  injury 
or  an  existing  otitis  media,  it  is  to  be  carefully  distinguished  from 
meningitis.  This  cannot  be  done  unless  there  are  focal  symptoms  and 
optic  neuritis;  but  abscess  may  be  suspected  if  rigors  are  associated 
with  other  .symptoms. 

If  cerebral  symptoms  develop  suddenly  after  a  period  of  latency, 
either  from  rupture  of  the  abscess  or  rapid  extension  of  softening,  the 
phenomena  are  those  of  apoplexy.  Abscess  can  then  be  suspected 
only  when  the  cause  is  indicated  by  the  previous  history. 

When  pressure-symptoms  exist  abscess  is  to  be  distinguished  from 
tumor  by  the  history,  by  its  relatively  rapid  development,  and  by  the 
occurrence  of  rigors  and  fever.  Pronounced  localizing  symptoms  are 
in  favor  of  tumor. 


892  SPECIAL  DIAGNOSIS. 


Tumors  of  the  Brain  and  its  Membranes. 

Tumors  of  the  brain  and  its  membranes  are  twice  as  common  in 
males  as  in  females.  The  tubercular  and  syphilitic  are  the  most  com- 
mou,  and  next  in  frequency  gliomata  and  sarcomata.  Gowers  states 
that  the  tubercular  and  sarcomatous  tumors  (including  glioma  and 
myxoma)  constitute  about  four-fifths  of  non-syphilitic  brain-tumors. 
The  same  author  states  that  three-fourths  of  the  tubercular  tumors 
occur  during  the  first  twenty  years  of  life,  and  one-half  in  persons 
under  ten  years  of  age.  They  occupy  preferably  the  cerebellum  and 
cerebrum. 

Headache,  optic  neuritis,  vomiting,  mental  changes,  and  giddiness  are 
the  most  constant  symptoms.  The  headache  is  constant,  but  subject 
to  paroxysmal  exacerbations;  occasionally  it  is  unbearable,  unfits  the 
patient  for  all  mental  work,  prevents  sleep,  and  may  induce  great 
despondency.  Optic  neuritis  is  nearly  always  present,  regardless  of 
the  seat  of  the  tumor.  Vomiting  is  more  common  when  the  tumor  is 
at  the  base  of  the  cerebrum  or  in  the  cerebellum.  The  most  common 
form  of  mental  change  is  a  gradual  decadence  of  mental  powers,  but 
there  may  be  more  or  less  marked  mental  aberration,  and  disorders  of 
speech,  consisting  oftener,  perhaps,  in  a  slow  syllabic  utterance  than 
in  difficult  articulation.,  The  attending  paralysis  is  usually  a  hemi- 
plegia or  a  monoplegia,  which  develops  gradually  and  is  associated 
with  contracture.      Occasionally  the  palsy  is  bilateral. 

Convulsions  are  common ;  they  may  be  general,  or  the  mode  of  onset 
may  be  such  as  to  indicate  the  seat  of  irritation  in  the  brain.  Thus 
if  the  foot  or  hand  is  first  attacked,  it  points  to  the  respective  motor 
centre. 

As  a  rule,  the  course  of  brain-tumors  is  slowly  progressive  to  a  fatal 
issue  in  from  six  months  to  two  years.  Syphilitic  tumors  offer  the 
best  prognosis,  aud  it  is  possible  for  tubercular  tumors  to  become  quies- 
cent and  encapsulated.     (See  Cerebral  Localization.) 

Multiple  Sclerosis. 

Multiple,  disseminated,  or  insular  sclerosis  is  a  chronic  degenerative 
affection  of  the  brain  and  spinal  cord  which  occurs  most  frequently 
before  middle  age  and  in  persons  of  nervous  heredity.  Its  most  con- 
stant symptoms  are  intention-tremor,  scanning  speech,  and  nystagmus; 
the  reflexes  are  exaggerated,  the  muscles  spastic,  giving  rise  to  a  cho- 
reoid,  jerky  incoordination,  especially  marked  in  the  arms;  late  in  the 
disease  the  muscular  power  may  be  greatly  diminished.  Transient 
paralyses  often  occur,  particularly  of  the  ocular  muscles.  Disturbance 
of  sensation  is  not  characteristic  of  the  affection,  but  it  may  be  met 
with  as  irregularly  distributed  anaesthesia  or  as  paresthesia. 

There  may  be  contraction  of  the  field  of  vision  before  optic  atrophy 
is  discoverable;  the  latter  is  often  developed  in  one  eye  first.  Other 
symptoms  occasionally  present  are  vertigo,  vomiting,  palpitation,  and 
apoplectiform  seizures.  A  peculiar  and  very  constant  symptom  is  the 
attacks  of  forced  laughing,  to  which  persons  suffering  from  this  disease 


DISEASES  OF  THE  NERVOUS  SYSTE3I.  893 

are  liable.  The  general  health  of  the  patient  remains  good,  and  he 
shows  surprising  contentment;  occasionally  there  is  considerable  im- 
pairment of  mental  power,  which  may  progress  to  complete  dementia. 

Toward  the  close  of  the  disease  there  are  bulbar  symptoms,  such  as 
interference  with  respiration  and  deglutition. 

The  duration  of  the  disease  is  variable  and  its  progress  is  not  steadily 
retrograde;  there  are  periods  when  the  disease  appears  to  be  stationary. 
As  a  rule,  it  lasts  from  two  to  six  years,  but  may  continue  twice  as 
long.  The  prognosis  is  fatal;  but  the  probability  of  length  of  life  is 
to  be  judged  from  the  rapidity  with  which  the  disease  progresses  and 
the  presence  or  absence  of  bulbar  symptoms  and  of  complications — 
such  as  disease  of  the  kidneys  and  bedsores. 

It  is  distinguished  from  locomotor  ataxia  by  the  fact  that  the  incoor- 
dination is  most  marked  in  the  arms  and  that  the  reflexes  are  exagger- 
ated, not  diminished  or  absent. 

From  general  paralysis  of  the  insane  it  is  distinguished  by  the 
absence  of  mental  changes;  by  the  articulation  being  slow,  but  accent- 
uated and  scanning,  whereas  that  of  paretic  dementia  is  hesitating  and 
indistinct,  owing  to  difficulty  in  pronouncing  certain  consonants  and 
to  spasm  of  the  tongue  and  lips;  by  the  absence  of  tremulousness 
about  the  mouth,  as  seen  in  paretic  dementia,  and  of  the  hallucinations 
and  morbid  impulses  of  the  latter.  Pupillary  symptoms  are  less  com- 
mon in  sclerosis  than  in  general  paralysis  of  the  insane. 

From  paralysis  agitans  it  is  distinguished  by  the  irregularity  of  the 
incoordinated  movements,  and  by  the  fact  that  they  cease  when  the 
patient  is  at  rest;  whereas  in  paralysis  agitans  the  movements  are  con- 
stant, rhythmic  tremors.  Moreover,  the  characteristic  defects  in  artic- 
ulation are  wanting  in  the  latter,  and  so  are  mental  changes. 

Glosso-labio-laryng-eal  Paralysis. 

Glosso-labio-laryngeal,  chronic  bulbar,  or  progressive  bulbar  paral- 
ysis is  a  chronic  degeneration  of  nerve-nuclei  in  the  medulla,  occurring 
most  frequently  after  middle  life,  and  characterized  by  slowly  progres- 
sive loss  of  the  power  of  articulation  and  of  deglutition,  with  atrophy 
of  the  muscles  concerned.  The  earliest  symptoms  manifest  themselves 
in  the  tongue;  there  is  difficulty  in  pronouncing  words  containing  the 
lingual  consonants,  particularly  I  and  t.  At  first  the  difficulty  is  noticed 
only  when  the  patient  is  fatigued,  and  it  can  be  overcome  by  effort; 
but  eventually  it  is  uncontrollable.  The  patient  gradually  loses  the 
power  to  protrude  the  tongue.  In  a  short  time  the  lips  begin  to  lose 
muscular  power;  the  patient  can  no  longer  pucker  them,  as  in  whistling, 
and  has  difficulty  in  pronouncing  words  containing  the  labial  conso- 
nants, particularly  p  and  b.  Eventually  he  is  unable  to  close  the  lips, 
and  saliva  constantly  dribbles  from  them.  Before  the  condition  of  the 
tongue  and  lips  reaches  its  fullest  development  the  soft  palate  becomes 
affected,  and  subsequently  the  pharyngeal  muscles.  Paralysis  of  the 
latter,  Avith  that  of  the  tongue  and  soft  palate,  renders  deglutition  very 
difficult;  fluids  tend  to  regurgitate  into  the  nose,  and  solid  substances 
and  fluids  find  their  way  into  the  larynx.    The  condition  of  the  patient 


894  SPECIAL  DIAGNOSIS. 

is  pitiable;  the  intellect  is  undisturbed,  so  that  he  is  fully  conscious  of 
his  condition;  in  fully  developed  cases  the  only  sound  he  can  make  is 
from  the  larynx.  The  meaning  of  the  sounds  has,  therefore,  to  be 
guessed  from  his  gestures.  Sensation  of  the  affected  parts  is  not  im- 
paired, though  reflex  action  is  lost.  The  patient  is  sometimes  easily 
moved  to  tears  or  to  laughter,  and  during  such  emotions  the  paralysis 
of  the  lower  part  of  the  face  becomes  very  conspicuous. 

Progressive  bulbar  paralysis  is  often  found  in  association  with  pro- 
gressive muscular  atrophy,  with  or  without  spastic  paraplegia. 

The  course  of  the  disease  is  progressive  to  a  fatal  issue  in  from  one 
to  five  years.  There  may,  however,  be  periods  of  temporary  arrest  of 
the  disease.  Death  occurs  from  exhaustion  depending  upon  insufficient 
nourishment,  from  bronchitis  or  pneumonia  excited  by  particles  of  food 
being  inspired,  or  from  failure  of  respiration  or  heart. 

Chronic  Hydrocephalus. 

Hydrocephalus  implies  an  excess  of  fluids  within  the  skull,  either  be- 
neath the  dura  or  within  the  ventricles.  The  former  is  called  exter- 
nal and  the  latter  internal  hydrocephalus. 

Internal  hydrocephalus  may  be  congenital;  it  may  occur  after  birth 
as  the  result  of  occlusion,  usually  from  inflammation,  of  the  openings 
into  the  fourth  ventricle,  or  it  may  occur  without  ascertainable  cause. 
It  is  characterized  by  a  progressive  enlargement  of  the  skull,  mental 
weakness,  frequently  verging  upon  idiocy  and  associated  with  physical 
weakness,  occasional  febrile  attacks,  convulsions,  and  vomiting.  The 
eyeballs  are  prominent;  there  are  nystagmus  and  optic  atrophy. 

In  the  congenital  form  the  disease  is  present  at  birth  and  the  enlarged 
head  may  form  a  serious  impediment  to  labor.  The  head  continues  to 
grow  in  size,  and  may  reach  huge  proportions.  The  fontanelles  remain 
open,  the  skull  is  very  thin,  and  the  frontal  portiou  projects  over  the 
face.  The  disease  may  progress  rapidly  and  end  in  death  from  convul- 
sions or  wasting  in  a  few  months  or  a  year,  or  at  some  stage  it  may  be 
arrested  and  the  patient  live  to  an  old  age — with,  however,  feeble  intel- 
lect and  physique,  and  liability  to  epileptic  seizures. 

In  the  acquired  form  the  disease  may  develop  at  any  age.  Enlarge- 
ment of  the  head  is  less  constant,  but  is  not  rare,  after  childhood;  in 
its  absence  a  positive  diagnosis  is  usually  impossible.  The  general 
symptoms  are  the  same  as  in  the  congenital  variety.  Life  is  not 
usually  prolonged  beyond  a  few  years,  and  death  may  occur  in  as  many 
months. 

Functional  Nervous  Affections.     Chorea. 

Chorea  occurs  almost  exclusively  between  the  fifth  and  twentieth 
years  of  life,  and  is  especially  apt  to  occur  about  the  age  of  puberty. 
It  is  nearly  three  times  as  common  in  girls  as  in  boys,  and  its  causa- 
tion is  influenced  by  a  nervous  heredity,  by  rheumatism,  by  the  season 
of  the  year  (spring),  and  by  pregnancy.  The  most  common  immediate 
cause  is  fright. 

It  is  characterized  by  spontaneous  muscular  twitching  and  jerky 


DISEASES  OF  THE  NERVOUS  SYSTEM.  895 

movements,  irregular  in  time  and  rhythm.  They  tend  to  increase  in 
frequency  and  range.  They  are  at  first  controllable  by  a  strong  effort 
of  the  will,  but  only  for  a  short  time.  Voluntary  movements  of  the 
affected  muscles  become  spasmodic,  jerky,  and  incoordinate.  Muscular 
power  is  generally  impaired,  but  not  often  to  a  very  marked  degree, 
and  is  very  rarely  lost.  Electrical  excitability  is  often  increased.  Sen- 
sation is  unimpaired.  The  most  common  mental  change  is  apathy, 
which  may  be  so  profound  as  to  border  on  dementia. 

The  disease  begins  gradually,  the  spontaneous  jerky  movements 
appearing  at  first  most  frequently  in  the  hands  or  face;  in  children 
regarded  as  emotional  and  excitable  the  movements  are  apt  to  be  over- 
looked until  they  become  more  pronounced.  The  hands  are  moved 
involuntarily,  or,  when  a  voluntary  movement  is  attempted,  it  is 
exaggerated  in  force  or  rapidity.  If  the  patient  attempts  to  pick  up 
an  object,  he  may  succeed  at  the  first  attempt  by  a  rapid  jerky  move- 
ment, or  his  hand  may  be  carried  beyond  the  object  and  several  efforts 
may  be  necessary  to  seize  the  object.  Sometimes  the  patient  is  unable 
to  relax  his  grasp  quickly.  The  mouth  is  drawn  to  one  side  or  the  eyes 
are  closed  by  spasmodic  winking.  The  head  may  be  jerked  forward, 
but  the  body  and  legs  are  not  affected  so  often  or  to  the  same  extent. 
By  degrees  the  movements  increase  in  frequency  and  range,  and,  in 
severe  cases,  become  so  nearly  continuous  that  rest  and  sleep  are 
obtained  with  difficulty,  and  may  be  so  violent  as  to  result  in  severe 
injury  to  the  patient. 

The  disease  may  be  limited  to  one  side  (hemichorea),  but  more  fre- 
quently one  side  is  affected  more  than  the  other,  and  it  is  most  intense 
in  the  arms. 

In  some  cases  there  is  moderate  pyrexia.  Heart-murmurs  may  be 
hsemic,  from  anaemia,  or  valvular,  from  mitral  disease,  or,  very  rarely, 
from  aortic  disease.  Endocarditis  is  very  common  as  a  complication. 
The  respiration  is  often  irregular  and  the  pulse  accelerated.  The  dura- 
tion of  the  disease  is  usually  under  six  months,  but  relapses  are  com- 
mon. Recovery  is  the  rule;  but  it  is  a  grave  complication  of  pregnancy, 
about  one-fourth  of  the  cases  proving  fatal. 

For  the  detection  of  the  rare  cases  of  paralytic  chorea,  in  which  loss 
of  power  is  more  conspicuous  than  spontaneous  spasmodic  movements, 
Gowers  suggests  that  the  hand  be  held  above  the  head,  an  action  which 
brings  choreic  movements  distinctly  into  play.  The  same  author  declares 
that  aasa  rule,  when  a  child  between  seven  and  twelve  years  of  age 
is  said  to  have  gradually  lost  the  use  of  one  arm,  the  disease  is  chorea." 

Paralysis  Agitans. 

Paralysis  agitans  occurs  most  frequently  between  the  fiftieth  and  six- 
tieth years.  A  nervous  heredity  has  some  determining  influence.  It 
is  excited  in  some  instances  by  shock,  by  fright,  or  by  great  mental 
anxiety;  injury  and  the  exhaustion  of  an  acute  disease  may  also  act 
as  exciting  causes.  It  is  characterized  in  its  fully  developed  form  by 
general  muscular  tremors,  which  are  spontaneous  and  rhythmical,  and 
are  associated  with  muscular  weakness  and  rigidity.     The  facial  ex- 


896  SPECIAL  DIAGNOSIS. 

pression  is  characteristic,  being  immobile  and  staring.  It  begins  most 
frequently  by  a  tremor  of  one  hand,  the  tremor  extending  to  the  arm, 
thence  to  the  leg  of  the  same  side,  then  to  the  opposite  arm,  and  being 
followed  by  muscular  weakness  and  rigidity.  A  leg,  however,  may  be 
attacked  first,  and  weakness  may  precede  the  appearance  of  tremor. 
The  tremor  itself  is  a  to-and-fro  movement  produced  by  alternate  con- 
traction and  relaxation  of  opposing  muscles,  and  continues  during  rest. 
The  rigidity  of  the  muscles  causes  flexion  of  the  fingers  and  hands 
and,  to  a  less  extent,  of  the  knees.  The  head  falls  forward,  and  the 
patient' s  gait  is  that  known  as  ' '  f estinating, ' '  short  quick  steps  being 
taken  in  rapid  succession  in  order  to  preserve  the  equilibrium.  At 
times,  even  when  sitting,  the  patient  will  suddenly  lean  forward  as  if 
about  to  fall;  this  is  known  as  propulsion.  When  lying  there  is  often 
great  difficulty  in  turning  over. 

The  muscles  do  not  waste  until  late  in  the  disease,  and  even  then  the 
atrophy  is  rarely  marked.  The  reflexes  are  usually  normal.  Dull 
pains  in  the  limbs  are  common  early  in  the  disease,  and,  later,  the  con- 
stant movements  cause  weariness.  A  subjective  sensation  of  increased 
heat  in  the  affected  parts  is  very  common ;  it  may  alternate  with  a  sen- 
sation of  cold,  or  the  latter  may  be  the  more  constant.  Pain  is  absent 
and  the  mind  is  unaffected,  except  that  it  shares  in  the  general  weak- 
ness. 

The  disease  progresses  very  slowly  and  may  last  many  years,  death 
generally  being  the  result  of  intercurrent  affections. 

Tetanus. 

Tetanus  is  an  acute,  infectious  disease  of  the  nervous  system,  the  essen- 
tial characteristic  of  which  is  persistent  tonic  spasm  of  the  muscles  of 
the  jaws  (lockjaw)  and  of  the  spinal  and  trunk  muscles.  The  disease 
begins  with  stiffness  of  the  jaw,  which  steadily  increases  until,  within  a 
few  hours,  there  is  complete  tonic  spasm  of  the  jaw.  The  neck-muscles, 
and  then  those  of  the  spine  and  trunk,  become  rigid,  so  that  the  body 
is  arched  backward  and  may  rest  upon  the  heels  and  head  (opisthot- 
onos). The  facial  muscles  share  in  the  spasm,  and  by  their  contrac- 
tion produce  a  horrid,  grinning  countenance  (risus  sardojiicus).  The 
contracted  muscles  become  painful,  and  there  is  also  epigastric  pain. 
The  rigidity  is  persistent,  but  is  interrupted  by  exacerbations  in  which 
the  phenomena  already  described  are  exaggerated,  and,  in  addition, 
respiration  is  embarrassed,  the  face  becomes  livid,  the  skin  bathed  in 
sweat,  aud  the  patient  is  further  distressed  by  increased  pain  in  the 
affected  muscles.  The  body  may  be  bent  forward  (emprosthotonos)  or 
laterally  (pleurosthotonos).  The  temperature  is  not  constant.  It  may 
remain  normal,  be  moderately  elevated,  or  hyperpyrexia  may  be  pres- 
ent, especially  toward  and  after  the  end  in  fatal  cases.  The  spasm 
ceases  during  sleep,  but  subsequently  returns. 

The  cause  of  the  disease  is  the  bacillus  of  tetanus,  which  produces 
the  convulsive  poison  tetanin.  Tetanus  frequently  follows  an  injury. 
Trismus  neonatorum  and  puerperal  tetanus  are  names  given  to  special 
varieties  which  occur  in  newborn  children  and  in  puerperal  women. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  897 

Tetanus  is  much  more  commoD  in  men  than  in  women,  and  Gowers 
states  that  three-fourths  of  the  cases  occur  between  the  ages  of  ten  and 
forty.  It  is  much  more  common  in  hot  than  in  cold  countries,  though 
cold  is  an  exciting  cause. 

In  traumatic  and  puerperal  cases  the  disease  usually  develops  in 
from  a  few  days  to  two  weeks  from  the  time  of  injury  or  childbirth  or 
abortion.  In  newborn  children  it  occurs  usually  during  the  first  week. 
It  lasts  from  two  to  six  weeks,  but  may  be  fatal  much  earlier,  or,  in 
rare  cases,  last  even  longer.  The  mortality  ranges  from  50  to  90  per 
ceut. ;  death  is  usually  the  result  of  heart-failure  or  asphyxia,  and 
occurs  during  an  exacerbation  of  the  tonic  spasm. 

Tetany. 

Tetany  is  an  acute  affection  of  the  nervous  system  characterized  by 
spasmodic  contractures,  generally  most  marked  in  the  hands.  These 
tonic  spasms  may  be  intermittent  or  continuous,  and  may  be  preceded 
by,  or  associated  with,  parsesthesia.  The  disease  is  afebrile;  it  may 
occur  at  any  age,  but  is  most  common  before  the  twenty-fifth  year. 
Diarrhoea,  cold,  pregnancy,  and  lactation,  the  acute  infectious  fevers, 
and  excision  of  the  thyroid  are  predisposing  causes;  in  rare  instances 
it  occurs  in  epidemics.  Tingling,  burning,  itching,  or  pain  often  pre- 
cedes the  spasm,  which  generally  seizes  upon  one  or  both  hands  first 
and  then  upon  the  feet.  The  fingers  are  flexed  at  the  metacarpo- 
phalangeal joints  and  the  thumbs  adducted;  the  other  joints  are  fixed 
in  extension.  The  arms  are  flexed,  but  not  strongly,  and  may  be 
adducted.  The  feet  are  extended  at  the  ankle,  and  inverted,  while  the 
toes  are  flexed.  In  mild  cases  the  spasms  are  not  more  extensive,  but 
in  severe  cases  the  muscles  of  the  trunk,  thorax,  head,  and  face  may  be 
involved,  with  characteristic  interference  with  function  and  distortion 
of  features.  The  spasms  may  be  intermittent,  remittent,  or  contin- 
uous, and,  in  severe  cases,  are  attended  by  cramp-like  pain.  Usually 
the  spasms  are  intermittent,  recurring  at  intervals  of  a  few  minutes  or 
hours.  As  in  tetanus,  when  very  severe  and  extensive,  respiration 
and  heart-action  may  be  embarrassed,  the  temperature  may  rise,  and 
profuse  sweating  may  occur;  but  the  paroxysms  become  by  degrees  less 
severe,  though  they  may  appear  first,  or  may  persist  during  sleep,  which 
is  not  the  case  in  tetanus.  The  nerves  and  muscles  in  the  intervals  are 
abnormally  excitable,  so  that  percussion  or  compression  of  them  or  of 
the  corresponding  arteries,  or  the  application  of  electricity,  readily 
excites  spasm  (Trousseau's  sign),  and  tapping  upon  the  facial  nerve 
where  it  winds  about  the  inferior  maxilla  causes  contraction  of.  the 
muscles  of  that  side  of  the  face.  Gowers  states  that  it  is  the  only 
affection  in  which  anodal-opening  tetanus  has  been  observed  in  man. 

The  duration  of  the  disease  is  from  a  few  days  to  a  few  weeks,  de- 
pending upon  its  severity  and  upon  whether  the  spasms  are  continuous 
or  intermittent;  it  may  be  prolonged  beyond  this  time,  especially  when 
the  cause  is  excision  of  the  thyroid.  Patients  are  liable  to  recurring 
attacks  upon  exposure  to  the  exciting  cause.  The  prognosis  is  favor- 
able to  recovery  in  the  large  majority  of  cases;  but  death  may  result 

57  " 


898  SPECIAL  DIAGNOSIS. 

from  the  combined  exhausting  effects  of  the  spasms  and  the  causal 
disease  (diarrhoea).  The  prognosis  is  most  unfavorable  in  the  form 
following  excision  of  the  thyroid. 

Writer's  Cramp. 

Writer's  cramp  is  the  most  important  of  a  series  of  neuroses  occur- 
ring in  persons  whose  occupation  necessitates  prolonged  use  of  a  special 
group  of  muscles.  According  to  the  occupation  of  the  sufferer  it 
is  common  to  speak  of  "telegrapher's,"  "pianoforte-player's/'  or 
"  stonemason's  cramp."  The  pathology  in  each  case  is  probably  the 
same,  and,  as  the  diagnosis  is  based  upon  the  evidences  of  disability 
associated  with  the  occupation  of  the  patient,  it  will  be  sufficient  to 
describe  the  symptoms  present  in  writer's  cramp  with  the  understand- 
ing that  they  cover  essentially  what  exists  in  the  other  varieties  of 
occupation-neuroses. 

Writer's  cramp  occurs  most  frequently  in  males  from  adolescence  to 
middle  life,  and  a  nervous  heredity  has  some  causal  influence.  Injury 
to  the  hand  or  arm  sometimes  brings  on  an  attack,  but  the  most  im- 
portant causal  factors  are  excessive  writing  performed  in  a  constrained 
position — the  hand  being  fixed  and  the  fingers  making  the  most  of  the 
motions.  The  same  or  even  a  greater  amount  of  writing  performed 
by  a  shoulder-motion  rarely  induces  the  cramp.  Moreover,  depression 
of  the  general  health,  especially  by  worry  and  anxiety,  is  apt  to  pre- 
cipitate an  attack.  The  characteristic  symptom  is  a  tonic  spasm  of 
the  thumb  and  forefinger  of  the  writing-hand,  less  frequently  of  the 
other  fingers,  but  sometimes  involving,  in  severe  cases,  the  hand  and 
forearm,  the  spasm  being  brought  on  sooner  or  later  after  each  attempt 
at  writing,  but  not  at  first  by  other  movements.  The  affection  almost 
always  comes  on  gradually;  the  act  of  writing  becomes  slow  and 
labored,  the  fingers  no  longer  contract  and  relax  readily,  but  are  stiff, 
and  occasionally  impart  to  the  pen  an  unexpected  motion,  as  the  result 
of  which  the  writing  becomes  angular,  uneven,  and  too  heavy.  The 
fingers  and  hand  also  ache  from  weariness.  The  spasm  tends  to 
increase  in  intensity  and  range,  and  the  writing  becomes  correspond- 
ingly irregular,  difficult,  and  painful,,  until,  in  severe  cases,  when  vari- 
ous makeshifts  have  failed,  all  writing  is  found  to  be  impossible.  In 
such  cases  other  movements  of  the  same  muscles  are  usually  defective, 
display  some  incoordination,  and  may  be  followed  by  spasm.  Tremor 
is  rare.  The  muscular  power  is  also  apt  to  be  impaired,  but  not  to  a 
great  degree. 

In  other  cases  the  patient  can  draw,  sketch,  or  play  the  piano,  but 
cannot  write. 

Pain  is  generally  present,  and  sometimes  is  a  prominent  symptom; 
usually  it  is  dull  and  aching  in  character,  but  it  may  be  neuralgic  and 
show  a  disposition  to  exceed  the  motor  symptoms  in  severity.  The 
disease  is  curable  if  taken  in  time  and  if  the  patient  can  cease  writing; 
but  the  duration  of  recovery  will  depend  upon  the  severity  of  the 
affection  and  the  general  strength  of  the  nervous  system.  The  affec- 
tion is  apt  to  recur. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  899 

The  diagnosis  from  degenerative  affections  of  the  brain  or  spinal 
cord,  such  as  general  paralysis  of  the  insane  and  disseminated  sclero- 
sis, in  which  cerebral  disease  is  sometimes  first  manifested  by  weakness 
and  incoordination  in  the  delicate  movements  of  the  hand,  is  to  be 
made  by  noting  the  fact  that,  in  the  degenerations,  other  acts  besides 
that  of  writing  induce  it  from  the  very  beginning,  and  that  there  are 
general  as  well  as  local  symptoms. 

From  neuritis  it  is  distinguished  by  the  cause,  the  mode  of  onset,  the 
presence  of  spasm,  and  the  absence  of  the  shooting-pains  and  tender- 
ness along  nerve-trunks  so  characteristic  of  neuritis. 

Epilepsy. 

Epilepsy  is  a  chronic  disease  of  the  brain  characterized  by  sudden 
convulsive  seizures  which  are  first  tonic,  then  clonic;  they  are  brief  in 
duration,  generally  accompanied  by  complete  loss  of  consciousness  and 
often  by  cyanosis,  and  occur  apart  from  organic  brain  disease,  toxaemia, 
or  other  obvious  cause.  The  attacks  are  not  followed  by  any  motor  or 
sensory  palsy,  nor,  usually,  by  any  immediate  mental  disturbance 
beyond  drowsiness. 

The  disease  may  occur  at  any  age,  but  the  great  majority  of  cases 
occur  before  the  twentieth  year.  Epilepsy  or  insanity  in  the  parents 
predisposes  to  it.  Exciting  causes  are,  convulsions  during  teething, 
especially  in  rickety  children,  worry,  fright,  and  anxiety,  acute  disease, 
particularly  scarlet  fever,  and  injuries  to  the  head. 

The  attacks  may  be  severe  {grand  mat)  or  mild  (petit  mat).  The 
severe  attacks  are  marked  by  loss  of  consciousness  and  falling  to  the 
ground,  if  the  patient  is  standing.  The  muscles  are  first  fixed  in 
tonic  rigidity,  the  eyes  are  open,  the  face  pale  and  then  cyanosed,  and 
the  respiration  embarrassed,  with  conjugate  deviation  of  head  and  eyes. 
Soon  the  cyanosis  lessens,  the  convulsive  movements  become  clonic 
instead  of  tonic,  respiration  comes  in  noisy  puffs,  and  by  degrees  the 
patient  falls  into  a  heavy  sleep,  or  awakes  to  complete  consciousness, 
but  generally  suffers  with  a  headache  for  some  time  after  the  attack. 
It  is  very  common  for  patients  to  have  warning  (aura)  of  the  approach 
of  an  attack.  This  may  consist  of  flashes  of  light  before  the  eyes,  or 
of  a  sensation  or  motion  in  the  arm,  face,  or  leg.  Sometimes  the 
convulsion  begins  in  one  arm  or  in  the  face.  During  the  convulsion 
biting  of  the  tongue  and  involuntary  discharge  of  urine  are  common  and 
very  characteristic  symptoms.  The  convulsions  recur  at  very  irregular 
intervals;  several  may  occur  in  one  day,  or  there  may  be  intervals  of 
weeks  and  months.  Moreover,  they  may  be  diurnal  or  nocturnal,  and 
when  exclusively  nocturnal  may  escape  detection  for  years. 

When  epilepsy  is  suspected  the  tongue  should  be  examined  for  signs 
of  having  been  bitten,  and  the  conjunctiva  inspected  for  possible  sub- 
conjunctival hemorrhage;  inquiry  should  be  made  as  to  the  occurrence 
of  nocturnal  enuresis. 

Rarely  there  is  a  series  of  convulsions  uninterrupted  by  intervals  of 
consciousness  (status  epilepticus). 

After  the  attacks  patients  are  conscious,  but  usually  dull  and  drowsy; 


900  SPECIAL  DIAGNOSIS. 

sometimes  they  are  very  quarrelsome,  and  may  commit  acts  of  vio- 
lence. 

In  the  milder  cases,  classed  as  petit  mal,  the  symptoms  vary  a  good 
deal,  but  they  consist,  in  general,  of  a  disturbance  of  sensation,  less 
frequently  of  motion,  associated  with  a  partial  loss  of  consciousness. 
The  patient  becomes  momentarily  giddy  and  faint,  sits  down  or  grasps 
an  object  for  support,  a  mist  comes  before  his  eyes,  and  he  loses  con- 
sciousness partly  or  completely,  but  only  transiently.  Slight  convul- 
sive movements  may  occur,  but  are  not  usual.  Urine  may  be  voided 
unconsciously.  The  patient  remains  dazed  for  some  moments  after  the 
attack,  and  may  commit  strange  actions;  that  of  undressing  is  said  to 
be  one  of  the  most  frequent. 

The  duration  of  the  disease  is  very  uncertain.  When  it  has  existed 
for  several  years  it  is  rarely  cured.  The  prognosis  is  best  when  the 
patient  is  over  twenty  years  of  age,  and  the  fits  occur  at  long  intervals, 
and  when  treatment  can  be  kept  up  continuously.  Death  does  not 
often  occur  during  a  convulsion,  but  fits  occurring  in  dangerous  places 
not  uncommonly  lead  to  accidental  death.  Life  is  shortened  by  it, 
but  it  is  difficult  to  say  to  what  extent. 

Hysteria. 

Hysteria  manifests  itself  by  permanent  symptoms,  known  as  the 
stigmata,  and  by  hysterical  attacks. 

The  stigmata  are  detected  only  by  special  examination.  The  patient 
is  not  usually  cognizant  of  their  presence. 

1.  Sensory  anaesthesia.  The  sensibility  of  the  surface  and  the 
special  senses  are  affected.  Analgesia  is  common.  It  may  be  general 
or  limited  to  an  arm  or  a  leg,  or  to  areas  on  the  limbs  or  trunk. 
Other  forms  of  cutaneous  sensibility  may  not  be  affected  at  the  same 
time,  although  any  variety  of  anaesthesia  may  occur.  The  muscular 
sense  may  be  lost.  Eye-symptoms,  due  to  disturbance  of  the  sensi- 
bility of  that  organ,  are  common.  Vision  may  be  distinct  or  dim. 
Limitation  of  the  visual  field  and  achromatopsia,  alteration  of  color- 
sense,  are  characteristic  features  of  the  disease.  Other  sensory  symp- 
toms are  diminution  of  hearing  and  loss  of  smell  and  taste. 

Hemiancesthesia  is  a  common  symptom  of  hysteria.  One-half  of 
the  body  seems  to  have  lost  consciousness.  The  skin  does  not  bleed 
freely  when  wounded.  The  mucous  membranes  are  affected,  as  the 
conjunctiva,  half  of  the  buccal  cavity,  and  the  tongue.  The  muscular 
sense  is  lost.  There  is  diminution  of  the  sense  of  hearing  on  the 
affected  side,  and  loss  of  the  sense  of  taste  and  smell  in  the  correspond- 
ing positions  Amblyopia,  or  amaurosis,  occurs  in  the  eye  of  the 
corresponding  side. 

Hyperpesthetic  regions  are  of  common  occurrence  in  hysteria.  These 
areas  or  "  hysterogenous  zones"  are  important  manifestations,  The 
sensitive  points  are  tender  on  pressure,  although,  when  the  patient's 
thoughts  are  diverted,  firm  pressure  is  not  felt.  The  hyperaesthetic 
areas  are  often  the  seat  of  pain.  They  may  be  extensive  or  quite  cir- 
cumscribed.    They  are  most  common  in  the  head  and  trunk,  on  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  901 

sides  of  the  chest,  under  the  breast,  and  on  the  sternum.  Hyperes- 
thesia of  the  spinal  columu  and  of  the  lower  abdominal  region  is  of 
very  common  occurrence.  The  whole  spine  or  small  portions  only  are 
affected.  A  slight  pressure  may  cause  severe  pain.  There  may  be 
hyperesthesia  of  the  eye,  ear,  aud  other  orgaus  of  seuse. 

2.  Hysterical  Paralysis.  A  frequent  manifestation  of  hysteria  is 
paralysis  of  one  or  more  groups  of  muscles.  It  may  occur  suddenly 
or  come  on  gradually.  The  paralysis  is  of  central  origin,  due  to  loss 
of  will-power  to  effect  contraction  of  the  muscles.  The  following- 
muscles,  in  order  of  frequency,  are  affected:  1.  The  muscles  of  the 
lower  limbs.  2.  The  vocal  cords.  3.  The  muscles  of  the  pharynx 
and  oesophagus.  4.  The  muscles  of  the  arms.  Hysterical  paralysis 
of  the  facial  muscles  does  not  occur.  In  paralysis  of  the  lower  limbs 
the  patient  may  be  able  to  move  the  legs  in  bed,  but  cannot  walk. 
Both  flaccid  and  spastic  paralyses  are  seen  in  hysteria.  The  tendon- 
reflexes  may  be  exaggerated. 

3.  Hysterical  Contractures.  Contractures  occur  alone,  or  with  anaes- 
thesia or  paralysis.  They  may  be  temporary,  but  often  become  perma- 
nent. Flexor  contractures  appear  in  the  hands  and  feet.  Extensor 
contractures  are  more  common  when  the  muscles  of  the  large  joints  are 
affected.  They  often  follow  a  convulsion,  and  may  be  limited  to  one 
extremity,  to  the  extremities  of  one  side  of  the  body,  or  to  the  lower 
extremities. 

4.  Vasomotor  Disturbances.  The  surface  of  the  skin  may  be  cool 
and  pale,  or  hot  and  red.  The  two  conditions  may  alternate.  The 
affected  portion  is  limited  to  an  extremity,  or  to  the  skin  about  a  joint. 
Hemorrhages  from  internal  organs,  as  hsematernesis,  haemoptysis,  and 
other  bleedings  may  take  place. 

Hysterical  fever  has  been  observed  at  the  time  of  an  attack.  Care 
must  be  taken  that  the  patient  does  not  cause  the  mercury  to  rise  by 
rubbing  and  pressing  the  bulb  of  the  thermometer.  The  temperature 
should  be  taken  in  the  rectum.  Modifications  in  the  secretory  organs 
are  common.  The  perspiration  may  be  increased  or  absent.  The  flow  of 
saliva  is  similarly  modified.  Ischuria  or  diminished  secretion  of  urine 
is  often  seen;  polyuria,  however,  is  more  common.  The  urine  is  light 
in  color  and  of  low  specific  gravity. 

5.  Visceral  Symptoms.  The  most  common  perversions  of  the  func- 
tions of  internal  organs  are  seen  in  those  belonging  to  the  gastrointes- 
tinal tract.  They  have  been  fully  dealt  with  in  the  sections  on  diseases 
of  these  organs.  In  addition  to  the  manifestations  mentioned,  hyster- 
ical tympanites  is  of  common  occurrence.  The  accumulations  of  gas 
simulate  tumor,  pregnancy,  or  peritonitis.  After  the  administration 
of  an  anaesthetic  the  hysterical  tumor  disappears.  The  gas  may  be 
removed  by  a  rectal  tube. 

In  other  portions  of  this  work  we  have  referred  to  the  cough  and  to 
a  peculiar  form  of  pulmonary  hemorrhage  seen  in  hysteria.  Increased 
frequency  of  respiration,  modification  of  the  normal  rhythm,  aud  dysp- 
noea, usually  unattended  by  distress  and  with  normal  pulse,  are  fre- 
quent phenomena  of  pulmonary  hysteria. 

In  cardiac  hysteria,  increased  frequency  of  the  heart's  action  on  the 


902  SPECIAL  DIAGNOSIS. 

slightest  emotion,  with  or  without  precordial  distress,  is  common. 
Hysterical  or  pseudo-angina  often  occurs.  Flushes,  both  general  and 
local,  are  common  symptoms. 

The  joints  are  frequently  affected  in  hysteria  (see  page  146). 

The  Mental  Constitution.  The  paramount  characteristic  of  the  patient 
is  selfishness.  The  various  forms  of  expression  of  feeling  are  almost 
always  excited  by  a  desire  to  attain  some  object.  The  patients  are 
irritable  and  emotional.  They  are  easily  depressed,  extremely  sensitive, 
and  subject  to  violent  emotional  expressions.  They  exaggerate  their 
sufferings  and  do  everything  to  command  attention  and  excite  sym- 
pathy. They  resort  to  sly  means,  not  to  say  actual  deception,  in  order 
to  obtain  their  desires.  The  will-power  is  lost  entirely  or  enfeebled. 
The  patients  are  usually  bright  and  vivacious,  or  emotional  in  rapid 
alternation.      Mental  characteristics  may  be  absent  entirely. 

The  general  nutrition  may  not  be  affected,  although  the  ill  nourished 
and  weakly  are  more  often  hysterical. 

Hysterical  Attacks.  A  so-called  attack  of  hysteria  may  be  the  first 
manifestation  of  the  disease,  or  the  patient  may  not  become  subject  to 
such  attacks  until  some  time  after  the  permanent  stigmata  have  devel- 
oped. The  attacks  may  be  made  up  of  subjective  symptoms  only,  the 
patient  complaining  of  vertigo,  anxiety,  precordial  or  respiratory  dis- 
tress, a  sense  of  fulness  in  the  throat,  or  a  lump  in  the  oesophagus 
(globus  hystericus).  The  objective  symptoms  of  hysteria  are  erratic 
and  exaggerated  displays  of  emotion  or  convulsive  movements,  with 
or  without  loss  of  consciousness.  Convulsions  may  be  preceded  by  emo- 
tional disturbance,  or  by  painful  sensations  in  the  chest  or  abdomen. 
In  the  minor  convulsions  the  movements  are  clonic  and  irregular. 
Each  series  of  convulsive  movements,  lasting  a  few  minutes,  is  fol- 
lowed by  an  emotional  attack,  when  consciousness  is  restored.  Instead 
of  convulsive  movements  the  patient  may  fall  into  a  relaxed  state,  with 
unconsciousness.  At  the  time  of  the  attack  the  abdomen  may  be  dis- 
tended with  flatus.  Urine,  light  in  color,  is  passed  in  large  amounts 
afterward. 

Hustero-epilepsy  is  the  most  exaggerated  convulsive  form.  The 
attack  may  come  on  suddenly,  or  be  preceded  by  milder  hysterical 
symptoms  such  as  globus  or  a  feeling  of  extreme  oppression.  Areas 
of  hypereesthesia  are  often  detected  at  this  time.  They  are  more  marked 
over  the  ovaries  and  the  upper  dorsal  vertebrae.  The  attack  is  divided 
into  four  stages.  In  the  first  stage  an  epileptic  paroxysm  is  simulated. 
The  convulsions,  which  are  at  first  tonic,  are  followed  by  gradual  relax- 
ation and  coma.  The  attack  lasts  longer  than  an  epileptic  attack. 
Following  the  convulsions  there  is  a  violent  display  of  emotion,  with 
contortions;  and  cataleptic  positions  are  assumed,  constituting  the  sec- 
ond stage.  In  the  third  stage  peculiar  attitudes  are  assumed  which 
express  the  various  passions.  This  period  is  followed  by  a  return  to 
consciousness,  with  delirium  and  hallucinations.  This,  the  fourth 
stage,  may  continue  for  several  days.  The  attacks  may  recur  for  days, 
followed  by  a  trance-like  state  which  likewise  may  continue  for  a  long 
period. 

The  diagnosis  of  hysteria  is  based  upon  the  presence  of  the  stigmata, 


DISEASES  OF  THE  NERVOUS  SYSTEM.  903 

the  peculiar  character  of  the  pain,  the  occurrence  of  emotional  attacks, 
and  the  globus  hystericus.  The  pain  and  other  subjective  symptoms 
are  influenced  by  suggestion.  The  paralyses  are  usually  associated 
with  anaesthesia.  They  are  always  variable.  All  forms  of  organic 
paralyses  may  be  simulated  in  hysteria. 

Neurasthenia. 

The  symptoms  may  be  general  or  local,  or  both.  The  patient  is 
usually  under  weight,  and  more  or  less  anaemic.  Debility  may  be  so 
marked  as  to  compel  the  patient  to  remain  in  bed.  Local  neurasthenia 
manifests  itself  in  cerebral,  spinal,  card io- vascular,  gastric,  and  sexual 
forms.  In  cerebral  neurasthenia  there  is  a  sensation  of  weight  and  ful- 
ness in  the  head,  with  flushes  of  heat.  The  patient  may  be  drowsy,  and 
is  usually  irritable  and  depressed.  He  suffers  from  headache,  usually  in 
the  back  of  the  head  or  the  neck.  Neck -weariness  is  a  common  symp- 
tom. Any  mental  effort,  even  of  the  slightest  degree,  is  accomplished 
with  difficulty.  The  patient  is  likely  to  complain  of  aching  and 
weariness  of  the  eyeballs,  after  reading  a  few  minutes.  Flashes  of 
light  are  often  present. 

Spinal  neurasthenia  was  formerly  termed  spinal  irritation.  There  is 
local  tenderness  all  along  the  spine  in  small  areas.  In  the  cervical 
spine  aching  is  common.  The  patients  weary  on  the  slightest  exertion, 
and  are  subject  to  backache  and  pains  in  the  legs. 

Cardio-vascular  symptoms,  as  palpitation,  irregularity,  increased 
frequency,  and  prsecordial  pain  are  common.  Vasomotor  symptoms 
are  most  pronounced.  Flushes  of  heat  and  transient  hypersemias  are 
frequently  seen.  Sweatings  may  occur.  Arterial  throbbing  is  very 
common.  The  capillary  pulse  can  often  be  seen.  Throbbing  of  the 
aorta  and  of  the  carotids  is  most  common  in  neurasthenia. 

The  gastro-intestinal  symptoms  have  been  discussed  in  Chapter  V. 

Neurasthenia  is  frequently  associated  with  lithsemia. 

Pain  in  the  Head. 

Pains  in  the  head  may  be  classified,  according  to  location,  into  those 
due  to  affections  of  the  scalp,  those  due  to  affections  of  the  cranium, 
and  those  due  to  intracranial  conditions. 

I.  Affections  of  the  scalp  are  to  be  further  classified  as  those  of 
the  skin,  those  of  the  occipito-frontalis  muscle,  and  those  of  the  nerves. 
The  occurrence  of  itching  and  burning  commonly  indicates  some  local 
condition  of  the  skin;  if  the  itching  is  slight,  seborrhoea  should  be 
looked  for;  if  more  severe,  eczema;  burning  and  itching  of  a  severe 
type  commonly  indicate  dermatitis  veueuata;  the  pediculus  capitis 
should  not  be  forgotten.  A  feeling  of  tension,  with  soreness,  accom- 
panies the  eruption  of  erysipelas.  Intense  local  irritations  are  caused 
by  burns  and  scalds,  the  latter,  however,  is  alone  likely  to  give  rise  to 
error,  because  the  hair  is  not  immediately  destroyed.  A  sore  feeling 
with  local  tenderness,  limited  to  a  sharply  defined  swelling,  with  a 
sensation  of  less  resistance  in  the  centre  and  some  darkening  of  the 


904  SPECIAL  DIAGNOSIS. 

skin,  is  diagnostic  of  a  bruise.  Hyperesthesias  of  the  scalp  frequently 
accompany  meningeal  and  cranial  affections,  and  there  are  even  local 
changes,  such  as  the  so-called  puffy  tumor  of  necrosis  of  the  inner  table 
of  the  skull. 

Sharp  pains  in  the  occipital  or  frontal  region,  increased  by  wrinkling 
the  scalp,  or  brief  pressure,  but  generally  relieved  by  firm  and  constant 
pressure,  occurring  with  irregular  periodicity,  and  associated  with 
meteorological  changes,  are  suggestive  of  occipital  myalgia.  The  diag- 
nosis is  confirmed  by  the  presence  of  other  symptoms  of  lithamiia. 

The  sensory  nerves  of  the  scalp  and  face  are  the  trigeminus  and  the 
branches  of  the  cervical  plexus.  The  distribution  is  as  follows:  the 
ophthalmic  division  of  the  trigeminus  is  distributed  to  the  eyeball, 
lacrymal  gland,  the  mucous  membrane  of  the  nose  and  eyelids,  the 
integument  of  the  nose  and  upper  eyelid,  the  forehead  and  the  anterior 
half"  of  the  hairy  scalp.  The  superior  maxillary  division  supplies  the 
skin  over  the  malar  bone,  and  that  of  the  lower  eyelid,  side  of  the 
nose,  and  upper  lip;  the  upper  teeth,  the  upper  part  of  the  pharynx, 
the  antrum  of  Highmore,  and  the  posterior  ethmoidal  cells;  the  soft 
palate,  tonsil,  and  uvula,  and  the  glandular  structures  of  the  roof  of 
the  mouth.  The  inferior  maxillary  division  is  distributed  to  the  side 
of  the  head,  the  upper  anterior  portion  of  the  external  ear,  the  external 
auditory  canal,  the  lower  lip,  and  lower  part  of  the  face;  the  tongue, 
the  mouth,  the  lower  teeth  and  gums,  the  salivary  glands,  and  the  artic- 
ulation of  the  jaw.  The  great  occipital  is  distributed  to  the  back  of 
the  head,  the  small  occipital  to  a  narrow  region  just  in  front  of  it,  and 
the  great  auricular  to  the  skin  of  the  posterior  portion  of  the  pinna 
and  the  skin  over  the  mastoid  and  parotid  gland. 

Neuralgia  occurs  in  the  form  of  paroxysms  of  pain,  accurately 
located  in  the -course  of  one  or  more  of  the  nerve-trunks,  and  presenting 
points  of  special  sensitiveness  where  the  nerve  emerges  from  the  skull 
and  where  it  divides  for  its  cutaneous  distribution.  The  pain  is  usually 
relieved  by  firm  pressure,  but  it  is  to  be  rememberd  that  sharply  local- 
ized pressure  on  the  nerve-trunks  against  the  hard  skull  will  cause  a 
traumatic  tenderness  The  character  of  the  pain  is  variable;  it  may 
be  of  the  most  acute  or  rending  form,  or,  but  more  rarely,  a  persistent 
dull  ache;  it  may  be  throbbing,  or  occur  in  successive  paroxysms  at  brief 
intervals,  or  it  may  be  regularly  periodic.  There  are  often  associated 
vasomotor,  secretory,  and  motor  disturbances;  local  blushing  or  sweat- 
ing may  be  observed  along  the  course  of  the  nerve,  and  spasms  may 
occur  in  the  muscles  of  the  eyelids,  for  instance,  or  more  general  spasms, 
as  in  the  terrible  tic  douloureux,  distinguished  by  the  pain  from  tic 
convulsif.  The  commonest  seats  are  the  supraorbitals,  the  dentals, 
the  auricular  branches,  and  the  occipitals;  in  the  great  majority  of 
cases  it  is  unilateral. 

Paiu  simulating  neuralgia  is  frequently  due  to  some  local  irritation  ; 
foreign  bodies  have  been  known  to  cause  paroxysmal  attacks  for  a 
number  of  years,  until  removed;  diseases  of  the  bones  are  a  prolific 
source,  especially  in  the  case  of  the  jaws  and  the  cervical  vertebra?. 
Enlarged  cervical  glands  occasionally  irritate  the  great  auricular  or 
small  occipital  nerve.     Bilateral  occipital  pain  is  very  characteristic  of 


DISEASES  OF  THE  NERVOUS  SYSTEM.  905 

cancer  of  the  cervical  vertebrae.  In  these  cases  there  is  usually  pain 
on  movement  of  the  head  or  pressure  upon  it,  aud  some  stiffness  of 
the  neck.  Intracranial  growths  occasionally  cause  pains,  usually 
paroxysmal,  limited  to  one  of  the  branches  of  the  trigeminus. 

Certain  of  the  cephalic  nerve-pains  are  symptomatic  of  disturbance 
in  the  associated  but  distant  nervous  distribution.  Pain  in  the  region 
supplied  by  the  ophthalmic  division  is  very  common  in  influenza.  It 
is  usually  dull,  aching,  and  continuous,  increased  by  pressure  and  any- 
thing; tending  to  increase  congestion.  A  severe,  acute  attack  of  indi- 
gestion  will  produce  ocular  and  supraorbital  pain.  Refractive  lesions 
of  the  eye  cause  the  same  kind  of  pains,  which  are,  however,  increased 
by  using  the  eye  and  relieved  by  rest  and  atropine.  The  use  of  the 
latter  is  an  important  diagnostic  procedure.  Pain  in  the  temporal 
region  aud  the  external  auditory  meatus  is  often  due  to  intense  irrita- 
tion of  some  of  the  branches  of  the  inferior  dental;  the  usual  cause  is 
cancer  of  the  tongue,  but  irritable  lingual  ulcer  may  also  produce  it, 
and  even  severe  inflammatory  conditions  of  the  lower  jaw.  The  pain 
is  described  as  sharp,  lancinating,  and  paroxysmal,  liable  to  exacerba- 
tions, especially  when  the  primary  lesion  is  irritated,  and  relieved  when 
it  is  alleviated.  Pain  may  be  caused  in  the  ear  alone  when  there  is 
irritation  of  the  teeth. 

Perhaps  in  the  majority  of  cases  of  cephalic  neuralgias  the  cause  is 
to  be  found  in  some  systemic  disturbance.  If  the  attack  is  preceded 
by  a  desire  to  sleep,  occurs  when  the  dew-point  is  high,  and  is  associ- 
ated with  increase  of  urates  in  the  urine,  it  is  probably  lithceniic ;  the 
pure  gouty  forms  are  most  apt  to  succeed  indulgence  in  rich  food  or 
red  meat,  and  there  is  ordinarily  irritability  of  temper.  Diabetic  neu- 
ralgias are  invariably  worse  as  the  amount  of  sugar  excreted  is  in- 
creased, and  there  are  usually  similar  affections  of  the  nerves  in  other 
parts  of  the  body.  Regularly  periodic  pains,  worse  in  the  spring  and 
fall,  occasionally  preceded  by  a  slight  chill  or  malaise,  suggest  chronic 
malaria.  The  diagnosis  can  readily  be  confirmed  by  examination  of 
the  blood,  and  by  the  detection  of  enlargement  of  the  spleen.  Syphilitic 
neuralgias  are  usually  worse  at  night;  the  pain  is  described  as  boring, 
and  may  be  periodical.  There  is  likely  to  be  some  thickening  of  the 
bones,  and  perhaps  a  diminution  of  elasticity  of  the  tissues,  and  almost 
always  local  tenderness.  The  pain  is  almost  immediately  relieved  by 
iodide  of  potassium.  In  anaemic  neuralgias  the  pain  is  not  characteristic, 
but  it  is  temporarily  improved  by  the  recumbent  posture  and  stimu- 
lants, and  is  worse  during  menstruation.  The  general  appearance  of 
the  patient  and  an  examination  of  the  blood  readily  suggest  the  cause. 
In  locomotor  ataxia  there  are  occasional  cephalic  crises  of  neuralgic 
nature;  these  come  on  suddenly  and  are  exceedingly  severe,  but  usually 
occur  only  at  long  intervals;  the  pain  is  shooting  or  stabbing  and  does 
not  remain  located  in  one  nerve-trunk.  Chronic  lead-  and  alcohol- 
poisoning  also  cause  neuralgias,  but  they  are  not  of  themselves  charac- 
teristic and  never  occur  as  isolated  symptoms,  being  frequently  associ- 
ated with  peripheral  neuritis. 

Dull,  burning  pains,  commencing  perhaps  with  a  chill,  and  accom- 
panied  by  febrile  symptoms,  indicate   inflammations  of    the   mucous 


906  SPECIAL  DIAGNOSIS. 

membranes  of  the  head.  A  dull,  persistent  headache  located  just  be- 
neath the  eyebrows  often  accompanies  coryza,  and  indicates  extension 
to  the  frontal  sinuses;  if  the  nose  alone  is  involved,  there  is  a  feeling 
of  fulness  and  occasional  sharp  paios  or  tickling  sensations.  A  feeling 
of  dryness  and  some  discomfort  on  swallowing  accompanies  the  various 
forms  of  stomatitis  and  pharyngitis;  in  the  latter  there  is  also  a  sen- 
sation of  tickling  and  fulness  in  the  ear,  due  to  extension  along  the 
Eustachian  tube.  Pain  at  the  angle  of  the  jaw,  with  tenderness,  and 
increased  on  swallowing,  almost  invariably  unilateral  and  associated 
with  swelling  of  the  parotid,  is  unmistakably  due  to  parotitis.  The  neu- 
ralgias and  inflammations  of  the  middle  ear  are  exceedingly  painful; 
they  may  consist  of  a  sharp  continuous  pain,  or  a  series  of  regular  exa- 
cerbations and  remissions,  or  a  throbbing  sensation;  pain  often  radiates 
to  the  jaws  and  side  of  the  face.  As  suppuration  occurs,  the  feeling 
becomes  one  of  extreme  tension  until  the  membrane  is  perforated, 
when  there  is  immediate  relief.  Tinnitus  throughout  the  whole  course 
of  the  case  is  very  common.  The  inflammations  of  the  eye  produce 
local  pain,  usually  causing  the  sensation  of  a  rough  foreign  body. 
Usually  there  is  a  slight  supraorbital  tenderness,  and,  in  iritis,  sharp 
pains  radiate  over  the  whole  area  of  distribution  of  the  two  upper 
branches  of  the  fifth.  Certain  ulcers  of  the  mouth  are  comparatively 
painless,  noma  often  developing  insidiously.  Syphilitic  ulcers  are  to 
be  distinguished  by  their  painlessness  from  simple  and  tubercular 
ulcers,  which  are  very  irritable,  and  carcinomata,  which  are  liable  to 
paroxysms  of  pain  even  when  not  irritated. 

It  may  not  be  out  of  place  to  mention  the  value  of  certain  anaesthe- 
sias as  diagnostic  signs;  thus  in  neuritis  of  branches  of  the  fifth  there 
may  be  cutaneous  anaesthesia  while  there  is  tenderness  over  the  nerve- 
trunk. 

II.  Affections  of  the  Cranium.  A  dull,  constant  headache, 
limited  to  a  small  area,  later  increasing  in  severity,  and  the  pain 
assuming,  perhaps,  a  boring  character;  tenderness,  often  very  severe, 
over  the  affected  area,  and  probably  slight  oedema  of  the  scalp,  with 
some  rigidity  of  the  muscles  of  the  neck,  and  the  ordinary  signs  of  the 
inflammatory  process,  indicate  inflammation  of  the  cranial  bones.  In 
the  simple  cases  there  will  usually  be  some  history  of  injury,  the  pains 
will  not  be  especially  periodic,  and  the  fever  will  be  irregular.  In  the 
syphilitic  cases  there  will  be  the  history  and  symptoms  of  infection, 
the  pain  will  become  worse  at  night,  and  usually  there  will  be  concom- 
itant rise  of  temperature.  The  pains  will  also  be  controlled  by  iodide 
of  potassium,  but  as  it  often  requires  enormous  doses  to  accomplish 
this  result,  the  failure  of  a  moderate  dose  should  not  be  considered  as 
excluding  syphilis. 

III.  Intracranial  Headaches.  Intracranial  headaches  are 
functional  or  organic.  Both  forms  may  be  acute  or  chronic.  The 
typical  acute  functional  headache  is  seen  in  the  more  or  less  common 
type  known  as  migraine  or  hemicrania. 

Migraine  is  a  periodical  neurosis  characterized  by  pain  in  the  trigem- 
inus and  other  cranial  nerves.  The  headache  is  usually  unilateral, 
and,  as  it  is  probably  due  to  vasomotor  disturbances,  is  always  associ- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  907 

ated  with  vasomotor  symptoms.  It  occurs  more  particularly  in  women, 
frequently  begins  in  early  childhood,  and  continues  throughout  adoles- 
cence. It  is  often  hereditary.  It  occurs  most  frequently  in  women 
who  suffer  from  anaemia  or  from  menstrual  difficulties.  It  sometimes 
occurs  in  the  early  stages  of  secondary  syphilis.  The  habit  which  pre- 
disposes to  the  headache  may  develop  after  long  physical  or  mental 
overexertion.  The  attacks,  however,  are  excited  by  overexertion, 
mental  excitement,  or  disturbances  of  digestion.  Pain  of  migraine  is 
possibly  situated  in  the  pia  and  dura  mater. 

Symptoms.  The  attack  develops  with  or  without  premonitions.  In 
each  individual  different  prodromal  symptoms  are  recognized  as  indi- 
cating the  approach  of  an  attack.  Undue  nervousness,  a  general  sense 
of  discomfort,  pressure  or  heat  in  the  head,  vertigo,  tinnitus,  spots 
before  the  eyes,  excessive  yawning,  and  repeated  chilliness  are  the  most 
common. 

Premonitory  Symptoms.  The  pain  is  most  frequently  felt  on  the  left 
side  of  the  head  first.  It  is  seated  in  the  anterior  frontal,  the  tem- 
poral, or  parietal  region.  The  pain  is  continuous,  and  increases  in 
intensity  to  the  height  of  a  paroxysm.  Painful  points  are  not  usually 
detected,  although  the  whole  skin  may  be  hypersesthetic.  The  patient 
is  sensitive  to  light  and  sound,  intolerable  nausea  intervenes,  and  vom- 
iting may  occur  at  the  height  of  an  attack.  The  eye-symptoms  are 
very  pronounced.  Flashes  before  the  eyes,  scintillating  scotoma,  or 
hemianopia  may  occur. 

The  vasomotor  symptoms  that  attend  the  attack  are  of  two  varieties, 
dividing  the  disease  into  the  spastic  and  angioparalytic  forms.  In 
spastic  migraine  the  skin  on  the  affected  side  is  cool,  the  forehead  and 
ear  pale,  the  temporal  artery  is  contracted,  the  pupil  is  dilated,  and 
the  flow  of  saliva  increased.  In  the  paralytic  form  there  is  redness 
of  the  face  on  the  affected  side.  The  temporal  arteries  are  dilated  and 
pulsate  strongly.  The  face  is  hot,  the  pupils  contracted,  and  there  is 
often  unilateral  sweating. 

Chronic  Headaches.  Chronic  headaches  of  functional  origin  are 
usually  habitual  in  the  sense  that  the  attacks  are  constant,  but  there 
may  be  longer  or  shorter  intervals  of  freedom  from  pain.  The  nerves 
affected  are  the  trigeminus,  and  the  four  upper  cervical  and  sensory 
branches  of  the  vagus  to  the  posterior  fossa  of  the  skull.  Three  types 
of  such  head-pains  are  seen:  ordinary  headache,  migraine,  and  neu- 
ralgia. Headaches  are  caused,  as  a  rule,  by  diffuse  irritations  located 
in  or  referred  to  the  peripheral  ends  of  the  nerve-tracts  above  referred 
to.  Neuralgias,  on  the  other  hand,  are  caused  by  irritations  of  the 
trunks  of  these  nerves. 

Causes.  1.  Hsemic.  a.  Ansemia.  6.  Diathetic  states  (gout,  rheu- 
matism, diabetes),  c.  Infections  (malaria,  syphilis,  specific  fevers. 
2.  Toxic  (lead,  and  other  mineral  poisons,  alcohol,  the  poison  of 
uraemia,  tobacco).  3.  Neuropathic  states  (epilepsy,  neurasthenia, 
chorea,  hysteria,  neuritis).  4.  Reflex  causes  (ocular,  nasopharyngeal, 
auditory,  gastric,  sexual,  uterine).     5.   Organic  disease. 

Headaches  are  divided  according  to  their  situation  into  frontal,  occip- 
ital, parietal,  vertical,  diffuse,  and  combinations  of  both.     The  most 


908  SPECIAL  DIAGNOSIS. 

common  forms  are  the  frontal,  the  frontal-occipital,  and  the  cliff  use. 
Ocular  headaches  are  usually  frontal  when  due  to  errors  of  refraction. 
"When  due  to  muscular  insufficiencies  they  are  occipital  and  cervical. 
Nasopharyngeal  headaches  are  dull  frontal  or  diffuse.  When  the 
pharyngeal  tonsil  is  enlarged  the  headache  may  be  dull,  frequently 
recurring,  and  seated  in  the  occipital  region.  In  follicular  tonsillitis 
and  in  obstruction  of  the  Eustachian  tubes  the  headaches  are  diffuse. 
In  disease  of  the  middle  ear  they  are  temporal  and  occipital.  Gastric 
or  dyspeptic  headaches  without  constipation  are  often  occipital,  some- 
times frontal.  With  constipation  and  intestinal  irritation  they  are  dif- 
fuse and  frontal.  Uterine  and  ovarian  headaches  are  occipital  and  ver- 
tical. Neuropathic  headaches  are  seated  on  the  top  of  the  head,  as  in 
clavus,  or  they  are  associated  with  spinal  irritation.  Neurasthenic 
headaches  are  usually  associated  with  a  sense  of  pressure  or  weight, 
and  are  seated  in  the  frontal  and  vertical  regions.  In  spinal  irritation 
the  pain  is  of  a  boring  character  in  the  occipital  region.  The  earliest 
symptom  of  the  neurasthenic  headache  is  neck-weariness  and  pain  in 

Fig.  177. 
Anaemia. 
Endometritis. 
Bladder. 


Constipation  ;  caries  of  incisor.s 

Error  of  eye-refraction.^       N 

Gastric  dvspepsia.      ^\/'<)  Ik   ^§f^--~-.S--?i.-/-*:''    nu  •*•        <.-..•         a. 

v  r       -\  (jp    ^*^         /     \7^p     ~'  Pharyngitis ;  otitis  media. 


Eye. 
_  /£_„  Decayed  teeth. 


Uterine. 

Spinal  irritation. 


Showing  the  location  of  pain  in  various  headaches.    (After  Dana,) 

the  neck.  The  neurasthenic  headaches  occur  in  brain- workers  when 
the  brain  and  eyes  are  overtaxed.  Headaches  in  epilepsy  are  severe, 
and  are  confined  to  the  vertical  or  occipital  region.  Organic  headaches 
are  usually  violent,  associated  with  fulness  and  throbbing.  They  may 
be  remittent,  becoming  more  intense  with  each  exacerbation.  The 
organic  headaches  may  be  due  to  inflammation,  to  abscess  and  soften- 
ing, to  tumor,  to  congestion  of  the  brain,  and  to  inflammations  in  the 
meninges.  Anything  which  increases  the  blood  will  increase  the  pain 
in  organic  headaches.  In  acute  inflammation  of  the  brain  the  pain  is 
agonizing,  continuous,  associated  with  vomiting  and  fever,  and  some- 
times delirium.  In  abscess  of  the  brain  the  pain  is  less  violent.  It 
is  occasionally  paroxysmal  and  attended  by  paralyses  and  disturbed 
intellection.  In  tumor  of  the  brain  the  headache  is  severe  and  parox- 
ysmal. In  congestion  the  pain  is  dull,  increased  by  stooping,  by  sleep, 
and  by  bodily  or  mental  fatigue.  Some  congestive  headaches  are  due 
to  violent  exercise,  and  are  relieved  by  bleeding  at  the  nose.  In  all 
congestive  headaches  the  face  is  flushed,  the  bloodvessels  are  turgid, 
and  the  vessels  in  the  eye  ground  will  be  found  to  be  overfilled.     In 


DISEASES  OF  THE  NERVOUS  SYSTEM.  909 

meningitis  the  pain  is  constant,  is  more  or  less  fixed,  and  sometimes 
very  sharp.  Syphilitic  headaches  are  frontal  or  temporal,  worse  at 
night,  and  often  periodic. 

Headaches  are  divided  according  to  the  character  of  the  pain:  1. 
Pulsating  and  throbbing.  2.  Dull  and  heavy.  3.  With  constriction, 
squeezing,  or  pressing.  4.  Hot  and  burning.  5.  Sharp  and  boring. 
The  headaches  of  the  first  class  are  usually  associated  with  vasomotor 
disturbances,  as  in  migraine ;  to  the  second  class  belong  the  toxic  and 
dyspeptic  headaches;  to  the  third  the  neurotic  and  neurasthenic;  to  the 
fourth  rheumatic  and  anaemic;  to  the  fifth  hysterical,  neurotic,  and  epi- 
leptic. Vertigo  is  a  common  accompaniment  of  the  dyspeptic  type  of 
headache,  situated  in  the  frontal  regions.  Somnolence  is  more  marked 
in  the  syphilitic,  anaemic,  and  malarial  headaches.  Nausea  is  more 
common  in  occipital  forms  of  headache. 

Duration.  Eye-strain  causes  occipital  pain,  which  is  rarely  per- 
sistent, but  comes  on  after  prolonged  use  of  the  eyes.  It  may  be  asso- 
ciated with  headache  in  other  parts,  due  to  other  causes.  In  chronic 
meningitis  the  headache  is  persistent  and  located  in  the  vertex  or  the 
parietal  regions.  When  thickening  of  the  meninges,  with  adhesions, 
takes  place  from  trauma,  there  is  constant  pain  with  frequent  exacer- 
bations, sensitiveness  of  the  head,  incapacity  for  study.  Ursemic 
headache  is  not  constant.  Persistent  headache  may  be  present  in  the 
latter  stages  of  Bright' s  disease  and  in  diabetes.  In  atheroma  pain  in 
a  part  or  the  whole  of  the  head  is  common.  It  may  be  persistent, 
though  subject  to  exacerbations  in  case  of  excitement  or  violent  exer- 
cise. Headache  following  study,  in  children,  is  due  to  brain-strain, 
to  eye-strain,  or  to  indigestion.  Persistent  headache  is  sometimes  due 
to  asthma.  In  rare  instances  headache  is  said  to  be  idiopathic.  Neu- 
ralgic headaches  are  usually  periodic  and  may  be  associated  with  throb- 
bings  or  pulsations.  They  are  associated  with  vasomotor  signs.  Hys- 
terical headaches  are  irregular  and  shifting;  they  persist  after  all  causes 
are  removed;  they  are  replaced  by  pain  in  other  parts  of  the  body. 
They  are  usually  associated  with  other  manifestations  of  hysteria. 


INDEX. 


A  BASIA,  59 

Ix.    Abdomen,  aspiration  of,   contraindi- 
cations to,  164 
color  of,  500 

diminution  in  size  of,  499 
disease   within,   subjective    symp- 
toms of,  494 
general  enlargement  of,  causes  of, 
496 
palpation  and  percussion   of, 
500 
local  enlargement   or    tumors    of, 

498 
markings  or  striae  on,  500 
method  of  marking  surface  of,  493 
movements  of,  500 
palpation    and    percussion    about 
centre  of,  506 
of    epigastric   region   of, 

505 
of    lower    quadrants    of, 

502 
of  pubic  region  of,  504 
peristaltic  movement  seen  through 

wall  of,  500 
point  of  puncture  in,  164 
quadrants  of,  contents  of,  494 
shape  of,  499 
superficial  veins  of,  500 
tumors  of,  epigastric  pulsation  in, 
389 
in  gastric  cancer,  542 
walls  of,  pain  in  disease  of,  495 
Abscess,  faecal,  503 
pelvic,  503 

perigastric  or  subdiaphragmatic,  505 
perinephritic,  723 

perityphlitic,    palpation   and   percus- 
sion of  abdomen  in,  502 
in  precordial  region,  pain  in,  407 
retropharyngeal,  486 
"  stitch-,"  cause  of,  167 
subdiaphragmatic,  distinguished  from 
enlarged  liver,  638 
Acetonemia,  710 
Acetonuria,  691 
Acid,  uric,  703 
Acromegaly,  65 
Actinomyces,  168 

in  sputum,  293 
Actinomycosis,  820 
of  mouth,  463 
of  tongue,  475 


Addison's  disease,  748 

bronzed  skin  in,  74 
Adenoids  of  nasopharynx,  483 
chest  in,  484 
examination  of,  483 
symptoms  of,  484 
pharyngeal,  facies  in,  121 
iEgophony,  272 

in  pleurisy,  342 
Age,  apparent,  56 

as  a  factor  in  diagnosis,  56 
Ague-cake,  659 
Ague,  dumb,  814 
Albuminuria,  causes  of,  684 

"cyclical"  or  "intermittent,"  685 
Albumosuria,  in  empyema,  345 
Alcoholism,  distinguished  from  apoplexy, 

888 
Amaurosis,  toxic,  855 
Amblyopia,  855 
Amoeba  dysenteriae,  166,  588 
in  faeces,  574 
or  coli,  in  sputum,  286 
Anaemia,  177,  738 

classification  of,  738 

clinical  divisions  of,  177 

from  constitutional  and  local  diseases, 

739 
gastric  symptoms  in,  556 
haemic  murmurs  in,  402 
heart-murmurs  in,  385 
hemorrhage  in.  76,  739 
idiopathic  or  pernicious,  740 
blood-changes  in,  741 
diagnosis  of,  742 
aetiology  of,  742 
post-mortem  lesions  in,  742 
local,  178 
lymphatic,  746 

Mackenzie's  rule  for  detecting,  135 
of  malnutrition,  740 
neuralgia  in,  905 
oedema  in.  96 
parasitic,  738 

pernicious,   confounded   with    gastric 
cancer,  544 
skin  in,  70 
secondary  or  splenic,  746 
splenic,  661 
toxic,  738 

venous  hum  in,  406 
Anaesthesia,  835 
dolorosa.  872 


912 


INDEX. 


Anaesthesia  in  hysteria,  90() 
in  leprosy,  826 
of  skin,  836 
spinal,  837 
Analgesia,  836 
Aneurism,  445 

of  aorta,  446  (see  also  Aorta). 

arterio-venous,  445 

aortic,  precordial  dulness  in,  365 

pulse-tracing  in,  399 
dissecting-,  445 
mycotic,  446 
precordial  pain  in,  408 
pulmonary  hemorrhage  in,  303,  304 
thoracic,  decubitus  in,  57 
varicose,  445 
Angina  Ludovici,  486 
pectoris,  409 

in  aortic  regurgitation,  429 
arterial  sclerosis  in,  445 

tension  in,  393 
atheroma  of  coronary  arteries  in, 

425 
cardiac  lesions  with  which  asso- 
ciated, 409 
diagnosis  of,  409 
false,  410 
pain  in,  409 
Angle  of  Ludwig,  234 
Anilines,  basic,  157 
Ankle-clonus,  841 

Ankylostomum  duodenale,  578,  739 
Anorexia,  536,  550 
Anthracosis,  327 
Anthrax,  822 

bacillus  of,  170,  823 
distinguished  from  carbuncle,  824 
Antrum,  abscess  of,  205 
Anuria,  in  movable  kidneys,  725 
Aorta,  abdominal,  pulsation  of,  389 
aneurism  of,  446 

abdominal  pain  in,  495 
auscultatory  percussion  in,  451 
conditions  with  which  confounded, 

452 
confounded  with  phthisis,  447 
diagnosis  of,  452 
distinguished  from  splenic  tumor, 

662 
epigastric  pulsation  in,  389 
murmurs  in,  451 
physical  signs  of,  449 
possible   positions  of  impulse  in, 

450 
pressure  symptoms  in,  447 
pulse  in,  451 
seats  of  rupture  of,  448 
special  symptoms  of,  448 
tracheal  tugging  in,  451 
atheroma  of,  cardiac  murmurs  in,  387 
disease  of,  pain  in,  408 

of  valves  of,  murmur  in  arteries 
in,  401 
pulsation  of,  in  Glenard's  disease,  610 
thoracic,  pulsation  of,  388 
Aortic  incompetency,  428 


Aortic  incompetency,  arteries  in,  430 
capillary  pulse  in,  430 
double  murmur  in  crural  arterv 

in,  401 
general  symptoms  of,  428 
murmurs  in,  429 
physical  signs  of,  429 
presystolic  murmur  in,  436 
pulsation   in,  distinguished  from 

aortic  aneurism,  452 
pulse  in,  387,  430 

tracing  in,  399 
secondary  changes  in  circulation 

in,  387 
sudden  deaths  in,  429 
thrill  in,  362,  429 
obstruction,  430 

murmurs   in,  distinguished  from 

atheroma  of  the  aorta,  387 
secondary  changes  in  circulation 

in,  387 
thrill  in,  362 
stenosis,  pulse-tracing  in,  399 
Aphasia,  845 

forms  of,  846 
Apoplexy,  118,  886 

conditions    with   which    confounded, 

888 
definition  of,  181 
early  vomiting  in,  533 
in  arterial  sclerosis,  445 
ingravescent,  887 
in  interstitial  nephritis,  719 
premonitory  symptoms  in,  887 
seats  of  hemorrhage  in,  887 
subnormal  temperature  in,  111 
Appendicitis,  603 
abscess  of,  606 
catarrhal,  603 

confounded  with  dysmenorrhea,  604 
with  tubercular  peritonitis,  619 
with  typhoid  fever,  605 
decubitus  in,  58 

distinguished   from   acute   tubercular 
peritonitis,  608 
from  hip-joint  disease,  60S 
from  intestinal  colic,  562 
obstruction,  602 
from  intussusception,  503 
from  perinephritic  abscess,  607 
from  typhoid  fever,  780 
gangrenous,  607 
left-sided,  pain  in,  704 
McBurney's  point,  604 
micro-organisms  in,  603 
palpation  and  percussion  of  abdomen 

in,  502 
physical  signs  in,  604 
recurring,  603,  605 
septicaemia  in,  604 
symptoms  of  attack  of,  603 
tubercular,  619 
vomiting  in,  532 
with  perforation,  605 
without  perforation,  603 
Appetite,  deviations  of,  550 


INDEX. 


913 


Appetite  in  gastric  disease,  536 

loss  of,  in  uraemia,  710 
Apraxia,  847 
Aprosexia,  484 
Arcus  senilis,  127 
Argyria,  75 
Arteries,  auscultation  of,  401 

coronary,  disease  of,  425 

inspection  of,  388 

murmurs  in,  401 

in  arterial  sclerosis,  444 

in  the  neck,  pulsation  of,  388 

palpation  of,  390 

pressure-murmur  in,  401,  402 

pulsation  of,  411 

sclerosis  of,  causes  of,  443 

symptoms  and  physical  signs  of, 
444 

tension  of,  in  fever,  108 
Arterio-capillary  fibrosis,  443 
Artery,  tension  of,  prolonged,  400 
Arthritis,  gonorrhoea^  distinguished  from 
rheumatoid  arthritis,  759 

rheumatoid,  756 
hand  in,  130 

senile,  75 
Ascites,  496,  499 

in  cirrhosis  of  liver,  645 

conditions  with  which  confounded,  618 

distinguished  from  enlarged  liver,  638 
from  hydronephrosis,  672 

nature  of  fluid  in,  617 

in  pancreatitis,  664 

in  peritonitis,  617 
Aspiration,  163 

instruments  necessary  in,  163 
preparation  of,  163 

point  of  puncture  in,  164 

preparation  of  skin  for,  164 
Astasia,  59 
Asthma,  314 

causes  of,  315 

decubitus  in,  58 

dyspncea  in,  causes  of,  296 

hematuria  in,  687 

in  nasal  affections,  206 

peptic,  297 

premonitory  symptoms  of,  314 

uraemic,  297 
Atavism,  28 
Ataxia,  840 

febrile,  109 

hereditary,  879 
Athetosis,  134,  840 
Atrophy,  idiopathic  muscular,  881 

optic,  856 

progressive  muscular,  879 
Auscultation  (see  Chest). 

general  discussion  of,  53 


BACILLI,  153 
biological  characters  of,  154 
of  Booker,  582 
motility  of,  154 
spores  of,  153 


Bacillus  of  anthrax,  170,  823 
in  blood,  737 
coii  communis,  166,  579,  779 
comma,  580,  809 
Eberth's,  778 

Eisner's  culture  for,  779 
of  glanders,  169 

in  blood,  737 
of  influenza,  in  sputum,  292 
Klebs-Loffler,  805 
of  leprosy,  170 
pseudo-diphtheritic,  805 
of  syphilis,  168 
of  tetanus,  170 
tubercle  (see  also  Sputum). 
in  blood,  735 
in  chronic  phthisis,  331 
contrast-stains  for,  289 
cultivation  of,  291 
in  faeces,  582 
importance  of,  291 
in  pus,  168  (see  also  Sputum), 
methods  of  staining,  289 
in  sputum,  288 
typhoid  fever,  582,  778 
Backache,  48 

in  fever,  110 
in  oxaluria,  707 
Bacteria,  cultivation  of,  159 
facultative,  151 

morphology  and  biology  of,  151 
pyogenic,  166 
varieties  of,  151 
Bacteriology,  apparatus  necessary  in,  155 
preparation  of,  155 
collection  of  material  in,  156 
cover-slip  preparations  in,  156,  157 
culture-media  in,  159 
hanging-drop  in,  158 
inoculation  of  animals  in,  160 
Koch's  laws  in,  149 
methods  of  research  in,  150,  154 

staining  in,  157 
microscopical  examination  in,  157 
preparation  of  cultures  in,  160 
special  diagnosis  in,  162 
sterilization  in,  155 
Bacteriuria,  703 
Bell's  palsy,  862 
Bell-tympany,  271 
Bilbarzia  haematobia,  739 
Biliousness,  623 

bad  taste  in,  529 
Bladder,  examination  of,  by  endoscope,  673 
Blepharospasm,  860,  863 
Blindness,  functional,  855 
Blood,  acidity  of,  734 

alkalinity  of,  diminished,  734 
corpuscles  of,  727 
counting  corpuscles  of,  729,  732 
cover-slip  preparations  of,  156 
estimation  of  haemoglobin  of,  728 

white  cells  in,  732 
in  fever,  108 

in  gastric  contents,  tests  for,  518 
general  alterations  in,  177 
58 


914 


INDEX. 


Blood,  leucocytes  of,  increase  in,  732 
jS'eusser's  granules  in,  733 
varieties  of,  727 
naked-eve  apjiearances  of,  727 
parasites  in,  735 
-pressure,  hydrodynamic,  190 
hydrostatic,  190 
influence  of  vasomotors  on,  191 
recognition  of  high  and  low,  191 
-serum,  as  culture-media,  160 
Loftier' s  mixture  of,  160 
specific  gravity  of,  734 
Bloodvessels,  inflammation  of,  symptoms 

in,  184 
Boils,  bacteria  in,  166 
in  carcinoma,  188 
in  diabetes,  764 
Bones,  in  general  diagnosis,  142 

nodules  on,  142 
Bothriocephalus  latus,  739 
Boulimia,  537,  550 
Bradycardia,  395 
Brain,  abscess  of,  891 
anaemia  of,  886 
congestion  of,  886 
embolism  and  thrombosis  of,  890 
hemorrhage  into,  886 
internal  capsule  of,  lesions  of,  849 
lobes  of,  occipital,  848 
parietal,  848 
prefrontal,  845 
localization  of  areas  of,  843,  844 
motor  area  of,  844 
softening  of,  890 

distinguished  from  apoplexy,  889 
speech  centres  in,  845 
tumors  of,  892 

aspiration  of  vertebral  canal  in, 

165     ' 
distinguished  from  meningitis,  885 
ventricles  of,  hemorrhage  into,  888 
Brawny  induration,  99 
Breakfast,  Ewald's  test,  515,  517 
Breathing,  alterations  of  rhythm  in,  247, 
265 
amphoric,  267 
bronchial,  262,  266 

importance  of   expiratory  sound 

in,  267 
mode  of  determining,  267 
modifications  of,  267 
in  pericarditis,  4l8 
in  pleurisy,  342 
varieties  of,  266 
broncho-vesicular,  263 

in  disease,  268 
cavernous,  267 
Cheyne-Stokes,  248 
jerky  inspiration  in,  265 
metamorphosing,  274 
prolonged  expiration  in,  265 
puerile,  263 
"  transition,"  268 
tubular,  267 
types  of,  239 
vesicular,  262 


Breathing,  vesicular,  cause  of,  262 
diminished  or  absent,  264 
exaggerated,  263,  264 
feeble,  263 
Bronchi,  diseases  of,  306 
obstruction  of,  313 
causes  of,  295 
dyspnoea  in,  295 
Bronchiectasis,  312 
Bronchitis,  acute,  306 

in  rheumatism,  753 
capillary,  308 
chronic,  309 
in  febrile  diseases,  308 
fibrinous  coagula  in,  283 
foetid  or  putrid,  311 
plastic,  310 
specific,  312 
Bronchophony,  272 
Bronchorrhcea,  310 


CACHEXIA,  of  carcinoma,  188 
\J     in  gastric  cancer,  542,  543 

general  discussion  of,  56 

malarial,  818 
Caecum,  abscess  around,  608 

faecal  impaction  of,  502 

inflammation  of,  607 
Calculus,  renal,  722 
Cancer  (see  Carcinoma). 
Capillaries,  pulsating,  136 
Capsule,  internal,  lesions  of,  849 
Caput  Medusae,  627 
Carbolic-fuchsin  solution,  290 
Carbuncles,  in  diabetes,  764 

distinguished  from  anthrax,  824 
Carcinoma  of   bones,  distinguished  from 
osteomalacia,  68 

cachexia  of,  188 

diagnosis  of,  188 

facies  in,  120 

gastric,  weight  in,  64 

general  symptoms  of,  187 

Lobstein's,  618 

metastasis  in,  188 

skin  in,  70 

subcutaneous,  100 
Cardialgia,  534 
Carreau,  621 
Case-records,  21 
Cases,  plan  for  recording,  22 
Casts,  fibrinous,  in  plastic  bronchitis,  310 
Catalepsy,  840 
Catarrh,  chronic  post-nasal,  203 

dry,  203 

nasal,  201  (-see  also  Rhinitis). 

suffocative,  308 
Cavities,  pulmonary,  273 

cracked -pot  sound  in,  260 
friction- sound  in,  270 
Cercomonas  intestinalis,  575,  58S 
Cerebellum,  disease  of,  61,  852 

forced  movements  in,  852 
gait  in,  852 

hemorrhage  into,  S88 


INDEX. 


915 


Cerebrum  (see  Brain). 

Chalicosis,  327 

Charcot-Leyden  crystals,  200,  2S4,  285 

in  faeces,  574 
Chest,  in  adenoid  disease,  244 
of  nasopharynx,  484 
amount  of  air  in,  variations  in,  277 
angles  of,  233 

auscultation  of,  regophony  in,  272 
bell-tympany  in,  271 
bronchophony  in,  272 
friction-sound  in,  270 
jerking  inspiration  in,  265 
metallic  tinkling  in,  271 
methods  of,  261 
pectoriloquy  in,  272 
prolonged  expiration  in,  265 
pulmonary  cavities  in,   methods 

of  determining,  273 
rales  in,  268 

sounds  in  disease  in,  263 
in  health  in,  262 
cause  of,  262 
stethoscope  in,  261 
succussion  in,  271 
vocal  resonance  in,  271 

modifications  of,  272 
bilateral  diminution  of  size  of,  242 
enlargement  of,  240 
movement  in,  241- 
of  chronic  pleurisy,  348 
deductions   from   physical   signs   in, 

276 
deficient  expansion  of,  cyanosis  in,  73 
inspection  of,  236 
lines  of,  233 

local  changes  in  size  and  shape  of,  246 
mensuration  of,  274 
method  of  counting  ribs   and   inter- 
spaces of,  234 
movements  of,  239 
in  disease,  247 
palpation  of,  249 
percussion  of,  252 

amphoric  or  metallic  sound   in, 

260 
auscultatory  or  stethoscopic,  256 
cracked-pot  sound  in,  260 
degree  of  resistance  in,  256 
dulness  in,  255,  259 
flatness  in,  259 
immediate  and  mediate,  253 
method  of,  259 
object  of,  257 
pitch  in,  252,  255,  258 
plessor  in,  253 
pleximeter  in,  253 
position  of  patient  in,  254 
pulmonary  resonance  in,  254,  257 
diminished,  258 
increased,  257 
quality  of  sound  in,  252 
sounds  in  disease  in,  257 

in  health  in,  254 
superficial  and  deep,  256 
tracheal  tone  in,  255,  257 


Chest,  percussion  of,  tympany  in,  255,  258 
in  children,  255 

phthisical,  242 

regions  of,  233 

respiratory  capacity  of,  275 

rhachitic,  242 

shape  and  size  of,  237 

table  of  measurements  of,  275 

topographical  anatomy  of,  234 

transverse  groove  in,  244 

unilateral  changes  in  shape  of,  245 
Cheyne-Stokes  breathing,  248,  297 
Chiasm  and  tract,  optic,  diseases  of,  856 
Chickenpox,  789 
Chlorosis,  740 

gastric  symptoms  in,  556 

skin  in,  70 

venous  hum  in,  406 
Choked  disk,  856 
Cholera,  Asiatic,  807 

bacteriological  diagnosis  of,  809 
spirillum  of,  580 

Asiatics,  red  reaction  in,  810 

facies  in,  120 

infantum,  585 

bacilli  of  Booker  in,  582 

morbus,  592 

distinguished  from  Asiatic,  809 

nostras,  592 

spirillum  of,  582 

rash  in,  85 

tongue  in,  473 
Chorea,  894 

in  acute  rheumatism,  754 

vocal  cords  in,  227 
Choreiform  movements,  839 
Chyluria,  702 

Circulation,  local  disturbances  of,  177 
Cirrhosis,  symptoms  and  signs  of,  643 
Coin-test  in  pneumothorax,  349 
Colic,  560 

decubitus  in,  58 

hepatic,  561,  653 

intestinal,  560 

conditions  from  which  to  be  dis- 
tinguished, 561 

lead-,  561 

lithsemic,  624 

pancreatic,  535 

renal,  561 

in  calculus,  722 
phosphates  in,  705 

uterine,  562 
Collapse,  118 
Colon,  dilatation  of,  497,  610 

fajcal  accumulation  in,  distinguished 
from  hepatic  cancer,  642 
Coma,  alcoholic,  888 
.  apoplectic,  888 

diabetic,  710,  764 

uraemic,  710 

distinguished  from  apoplexy,  888 
Congestion  (see  Hypencmia). 
Constipation,  causes  and  symptoms  of,  567 

secondary  effects  of,  567 
Consumption,  galloping,  327 


916 


INDEX. 


Contractions,  fibrillary,  839 

rhythmical,  839 
Contractures,  hysterical,  901 
Convulsions,  840 

epileptiform,  839 

infantile,  118 

puerperal,  118 

ursemic,  709 
Cornea,  in  general  diagnosis,  127 
Corpora  quadrigemina,  disease  of,  850 
Corpus  callosum,  disease  of,  848 

striatum,  lesions  of,  849 
Coryza,  acute,  200 

syphilitic,  203 
Cough,  in  aortic  aneurism,  448 

in  capillary  bronchitis,  309 

centric,  300 

diagnostic  significance  of,  302 

dry,  301 

ear,  300 

in  cardiac  disease,  412 

in  chronic  tuberculosis,  335 

gastric,  537 

hysterical,  300 

laryngeal,  210 

in  mediastinal  disease,  453,  454 

in  mitral  incompetency,  434 

moist,  301 

in  nasal  affections,  195 

paroxysmal,  302 

in  pertussis,  302 

in  phthisis,  cause  of,  300 

in  pleurisy,  346 

of  puberty,  301 

in  pulmonary  affections,  300 

sound  of,  302 

stomach,  301 

tooth,  301' 

winter,  309 
Coxalgia,  distinguished  from  appendicitis, 
608 

pain  in,  147 
Cracked-pot  sound,  260 

in  pneumothorax,  349 
Cramp,  writer's,  898 
Cramps  in  calves,  uraemic,  710 
Craniotabes,  68,   123 
Cranium,  affections  of,  pain  in,  906 

fontanelles  of,  124 
Crises,  Dietl's,  669,  725 

gastric,  in  locomotor  ataxia,  551,  556 

of  pain,  43 
Cross-legged  progression,  61 
Croup,  217 

distinguished  from  bronchitis,  308 

false,  216 

membranous,  215 

spasmodic,  217 
Culture-media,  159 
Cultures,  smear  and  stab,  161 

tube  and  plate,  160 
Crus  cerebri,  disease  of,  850 
Curschmann's  spirals,  283 
Cyanosis,  causes  of,  72 

in  capillary  bronchitis,  309 

in  emphysema,  316 


Cyanosis  in  obstruction  of  lungs,  229 

Cyrtometer,  274 

Cysticercus  cellulosee,  100 

Cysts,  of  broad  ligament,  fluid  of,  175 

dermoid,  174 

hydatid,  fluid  of,  173 

ovarian,  174 

pancreatic,  175,  665 
fluid  of,  175 

puncture  of,  165 


DEAF-MUTISM,  hysterical,  128 
Deafness,  128 

in  adenoids  of  nasopharynx,  483 
from  drugs,  128 
hysterical,  128 
in  nasal  affections,  195 
Death,  sudden,  in  atheroma  of  coronary 

arteries,  425 
Decubitus,  57 
Degenerations,  the,  186 
Degeneration,  reaction  of,  843 
Dementia,    paretic,     distinguished    from 
multiple  sclerosis,  893 
paralytic,  larynx  in,  227 
Dengue,  810  _ 
Dermatitis,  distinguished  from  erysipelas, 

807 
Diabetes,  dyspnoea  in,  297 
gastric  symptoms  in,  557 
insipidus,  765 
mellitus,  763 

oxaluria  in,  707 
in  pancreatic  disease,  661 
neuralgia  in,  905 
Diaceturia,  692 
Diagnosis,  setiological,  18 

bearing  of  form  and  nutrition  of  body 

on,  61 
conditions  may  render  impossible,  19 
data  upon  which  based,  49 
electrical,  842 
methods  of,  19 
modern  methods  of,  20 
necessary  armamentarium  for,  54 
object  of,  18 

requisite  knowledge  for  making,  18 
should  be  complete,  20 
Diaphragm,  barrel-shaped,  240 
movements  of,  239 
paralysis  of,  dyspnoea  in,  298 

movements  of  abdomen  in,  500 
Diarrhoea,  catarrhal,  564 
chronic,  566 
of  constipation,  568 
membranous,  566 

microscopical  and  bacteriological  ex- 
amination of  stools  in,  565 
nervous,  563 

in  pulmonary  tuberculosis,  336 
symptoms  of,  564 
general,  566 
of  soldiers,  593 
Diatheses,  varieties  of,  55 
Diazo  reaction  in  typhoid,  774 


INDEX. 


917 


Diphtheria,  802 

diagnosis  of,  805 

distinguished   from    follicular  tonsil- 
litis, 482,  805 
from  scarlatina,  796 
false  membrane  in,  803 
Klebs-Loffler  bacillus  in,  805 
knee-jerk  in,  803,  806 
laryngeal,  215 

dyspnoea  in,  209 
membrane  of,  479 
myocarditis  in,  426 
nasal,  201 
prognosis  in,  804 
toxalbumins  in,  153 
ursemia  in,  804 
Diplococci,  152 
Diplococcus  pneumoniae  (see  Micrococcus 

Lanceolatus). 
Disease,  Addison's,  74 
blue,  73,  443 

classification  here  used,  23 
Da  Costa's,  685 
feigned,  32 
foot-and-mouth,  S24 
Friedreich's,  879 
heredity  in,  27 
infectious,  151,  769 
classes  of,  769 
definition  of,  769 
diagnosis  of,  770 
nasal  ulcers  in,  199 
influence  of  age  in,  24,  56 
of  family  history  in,  26 

relations  in,  26 
of  habits  in,  26,  56 
of  occupation  in,  25,  56 
of  place  of  residence  in,  26 
of  sex  in,  25 
Meniere's,  863 
mimicry  of,  32 

present,  importance  of  order  of  events 
in,  30 
method  of  eliciting  facts  in,  29 
previous,  as  a  factor  in  diagnosis,  29 
Raynaud's,  134 
Thomsen's,  141,  881 
vagabond's,  74 
weight  in,  64 
Diseases,  neurotic,  group  of,  28 
rheumatic,  group  of,  28 
scrofulous,  group  of,  28 
tuberculous,  group  of,  28 
Distoma  haematobium  in  kidneys,  724 
Dropsy  (see  QEdema). 

ovarian,  504 
Drugs,  rashes  caused  by,  84 
Duodenum,  catarrh  of,  585 

ulcer  of,  593 
Dupuytren's  contraction,  133 
Dysentery,  acute,  586 
amoebic,  587 

complications  of,  591 
diagnosis  of,  591 
symptoms  of,  587-591 
arthritis  and  neuritis  in,  587 


Dysentery,  catarrhal,  586,  589 

cessation  of  pain  in,  38 

diphtheritic  and  gangrenous,  590 

tropical,  586 
Dysmenorrhcea,  confounded  with  appendi- 
citis, 604 
Dyspepsia,  atonic,  554 

flatulent,  555 

gastric  pain  in,  535 

glossitis  in,  466 

in  gout,  759 

nervous,  554 

reflex,  556 
Dysphagia,  in  laryngeal  affections,  209 
Dysphonia,  210 
Dyspnoea,  in  aortic  aneurism,  448 

in  asthma,  296 

in  bronchial  obstruction,  295 

in  capillary  bronchitis,  308 

in  cardiac  disease,  411 

in  emphysema,  300 

causes  of,  293 

clinical  varieties  of,  298 

constant  and  paroxysmal,  299 

diagnosis  of,  299 

from  diminished  pulmonary  air-space, 
296 

due  to  pain,  298 

dyspeptic,  537 

expiratory,  209,  295,  300 

irregular  respiration  in,  299 

laryngeal,  128 

distinguished   from   other   forms 
of,  209 

in  laryngeal  affections,  208 

in  mediastinal  diseases,  128 

from  muscular  inaction,  297 

of  nervous  origin,  294 

in  obstruction  of  the  lungs,  229 

phrenic,  298 

rate  of  respiration  in,  299 

spasmodic  or  asthmatic,  296 

in  tracheal  obstruction,  294 

in  tuberculosis,  335 

ursemic,  710 
Dystrophies,  connective-tissue,  99 


EAR,  diseases  of,  pyaemia  in,  127 
in  general  diagnosis,  127 

tophi  in,  127 
Earache  in  nasal  affections,  195 

in  tonsillitis,  482 
Echinococci  in  kidneys,  724 
Eczema,    vesicular,     distinguished     from 

chickenpox,  790 
Electrical  diagnosis,  842 
Elephantiasis,  138 
Embolism,  179 

in  arterial  sclerosis,  445 

capillary,  180 

cerebral,  890 

fat  and  air,  180 

in  malignant  endocarditis,  423 

pulmonary,  318 

symptoms  of,  180 


918 


INDEX. 


Embryocardia,  375,  443 
Emphysema,  315 

accentuation    of    pulmonary    second 
sound  in,  374 

atrophic,  317 

chest  of,  240 

distinguished  from  pneumothorax,  350 

dyspnoea  in,  300 

hypertrophy  of  heart  in,  441,  442 

interlobular,  317 

subcutaneous,  98 
Emprosthotonos,  59 
Empyema,  343 

in  hepatic  abscess,  649 

indicanuria  in,  690 

pain  in,  306 

pulsating,  distinguished   from   aortic 
aneurism,  452 
Endocarditis,  422 

chronic,  424 

hemorrhage  in,  76 

malignant,  422 

distinguished  from  cerebro-spinal 
fever,  424 
miliary  tuberculosis,  330 
typhoid  fever,  423 
embolic  phenomena  in,  423 

in  rheumatic  fever,  753 

simple,  422 
Enteralgia,  560,  561 
Enteritis,  membranous,  566,  571 
Entero-colitis,  586 

distinguished  from  peritonitis,  615 
Enteroptosis,  610 
Enuresis,    in    adenoids    of    nasopharynx, 

484 
Epigastrium,  pain  in,  535 
causes  of,  407 

pulsation  in,  389,  437,  511 
Epiglottis,  inflammation  of,  216 
Epilepsy,  118,  899 

argyria  in,  75 

hystero-,  902 

Jacksonian,  in  uraemia,  709 
Epistaxis,  200 
Erysipelas,  806 
Erythema,  aetiology  of,  82 

character  of  eruption  in,  81 

classification  of,  81 

of  infectious  diseases,  85 

medicinal,  84 

nodosum,  83 

varieties  of,  82 
Erythromelalgia,  135,  178 
Esmarch's  tubes,  161 
Exophthalmic  goitre,  749 
Exophthalmos,  126 
Exudations,  165 

chylous,  173 

hemorrhagic,  172 

purulent,  166 

putrid,  172 

serous,  172 
Eye,  in  general  diagnosis,  125 

muscles  of,  spasms  of,  861 

in  scurvy,  762 


FACE,  in  children,  121 
cutaneous  affections  of,  123 

in  diagnosis,  119 

flushing  of,  in  fever,  110 

hemiatrophy  of,  121 

in  nervous  diseases,  121 

in  renal  disease,  712 

ruddy, 119 

in  scurvy,  762 

in  scleroderma,  99 

swollen,  65,  122 
Faeces,  bacteria  in,  579-582 

blood  in,  571,  573  _ 

chemical  examination  of,  582 

crystals  in,  574 

fat  and  pus  in,  572 

gall-stones  in,  571 

impaction  of,  502,  505 

microscopical  examination  of,  572 

moulds  and  yeasts  in,  579 

mucus  in,  572 

protozoa  in,  574 

vermes  in,  .576 
Facies,  Hippocratic,  121 

in  various  diseases,  120 
Farcy,  821 

Fauces  (see  Pharynx). 
Feet,  cold,  136 

Fermentation,  putrefactive,  153 
Fever  (see  also  Temperature). 

"  breakbone,"  810 

arterial  tension  in,  108 

ataxic  state  in,  109 

cerebro-spinal,  801 

distinguished  from  typhus,  783 

continued,  112 

in  coryza,  194 

course  of,  106 

crisis  and  lysis  in,  106,  107,  117 

daily  inversion  of,  107 
range  of,  107 

defervescence  in,  106,  113 

definition  of,  101 

determination  of,  101 

diagnostic  significance  of,  112 
intermittent,  114 

dyspnoea  in,  294 

ephemeral,  833 

eruptive,  cyanosis  in,  90 

fastigium  of,  106 

significance  of,  113 

general  causes  of,  112 
musculature  in,  117 

hectic,  facies  in,  120 

high,  dangers  in,  104 

hysterical,  901 

intermittent  hepatic,  111,  116,  632,  814 
in  hepatic  abscess,  647 
malarial,  811 

irregular  forms  of,  813 
in  tuberculosis,  334 
types  of,  104,  105 

malarial,  811 

miliary,  827 

modes  of  onset  in,  107 

nervous,  113 


INDEX. 


919 


Fever,  pernicious  malarial,  817 
pseudo-crises  in,  117 
pulse-rate  in,  108 
recrudescence  in,  107 
relapsing,  784 

distinguished  from  typhoid,  781 
spirillum  of,  785 
in  blood,  735 
remittent,  116 

malarial,  816 
respiration  in,  108 
rheumatic,  751 
scarlet,  792 

anginoid,  795 

conditions     with     which      con- 
founded, 795 
diarrhoea  in,  794 
malignant,  complications  and  se- 
quela? of,  795 
pulse  in,  395 
symptoms  of,  793 
throat  in,  793 
significance  of  age  and  sex  in,  117 

initial  stage  in,  113 
simple  continued,  833 

distinguished  from  typhoid, 
780 
"  spotted,"  802 
symptoms  of,  107 
cerebral,  108 
thermic,  833 
types  of,  104 

continued,  117 
typhoid,  abortive,  776 
albuminuria  in,  772 
ambulatory,  776 
bacillus  of,  582 

Baruch's  diagnostic  sign  of,  780 
bronchitis  in,  308 
complications    and    sequelae    of, 

777  _ 
conditions     with      which      con- 
founded, 605,  780 
defervescence  in,  114 
diagnosis  of,  779 

bacteriological,      improved, 
779 
diazo-reaction  of  urine  in,  774    . 
distinguished  from  influenza,  800 
from  acute  miliary  tubercu- 
losis, 330 
from  malignant  endocarditis, 

423 
from  pernicious  malaria,  818 
from  trichinosis,  828 
from  typhus,  784 
Eberth's  bacillus  in,  778 
eruption  in,  774 
facies  in,  120 
faecal  impaction  in,  568 
fastigium  in,  113 
leucocytosis  in,  733 
malignant,  777 
mode  of  invasion  in,  771 
nervous  symptoms  in,  774 
parotitis  in,  486 


Fever,     typhoid,    Pepper's     premonitory 
signs  of,  771 
period  of  incubation  in,  771 
pulmonary  form  of,  777 
pulse  in,  393,  394 
pulse  and  heart-sounds  in,  772 
respiration  in,  774 
spleen  in,  771 
temperature  in,  772 
wasting  in,  108 
typhus,  781 

confounded  with  acute  Addison's 

disease,  748 
distinguished  from  typhoid,  781 
from  variola,  788 
yellow,  818 
Fibroma,  of  larynx,  222 
Filaria,  forms  of,  738 

method  of  searching  for,  738 
sanguinis  hominis,  737,  739 

in  urine,  724 
in  "sleeping  sickness,"  738 
Fingers,  club-shaped,  133,  136 
deformities  of,  132,  133 
glossy  skin  in,  135 
tophi  in,  132 
Fits,  118 

Flagellae,  staining  of,  158 
Flatulency  in  gastric  affections,  533 
Flat-foot,  pain  in,  45 
Fontanelles,  124 

Foot,  gangrene  of,  in  arterial  sclerosis,  445 
Morton's  painful  affection  of,  45 
-and-mouth  disease,  stomatitis  in,  462 
perforating  ulcer  of,  135 
tabetic,  146 
Fremitus,  friction-,  251,  270 
in  pericarditis,  415 
rhonchial,  251 
vocal,  in  health,  250 
in  disease,  250 
Friction,  fremitus  in,  415 
mediastinal,  421 
pericardial,  362,  415 

distinguished  from  pleural,  378 
of  perihepatitis,  635 
peritoneal,  502 
pleural,  270,  416 

in  emphysema,  317 
in  tuberculosis,  328 
pleuro-pericardial,  378,  415 
Friedreich's  sign  of  cavity,  274 


H  ABBETT'S  solution,  290 
vJ     Gait  and  attitude  in  general  diagnosis, 
57 
in  various  nervous  affections,  59 
Gall-bladder,  aspiration  of,  636 
cancer  of,  656 

enlargement      of,     conditions      with 
which  confounded,  655 
distinguished   from   hydatid  dis- 
ease, 651 
inflammation  of,  654 
palpation  of,  635 


920 


INDEX. 


Gall-bladder,  simple  enlargement  of,  654 
tumors  of,  654 

distinguished  from  movable  kid- 
ney, 726 
Gall-ducts,  cancer  of,  distinguished  from 
hepatic  cancer,  642 
diseases  of,  652 
gallstones  in,  652 
obstruction  of,  654 

by  gallstones,  656 
stenosis  of,  symptoms  in,  656 
Gallstones,  652,  653 
accidents  of,  657 
in  gall-ducts,  656 
Gangrene,  185 

in  arterial  sclerosis,  445 
in  diabetes,  764 
of  internal  organs,  185 
Gastralgia,  535,  550 
hysterical,  552 
in  morphinism,  44 
neurasthenic,  551 
Gastrectasia,  546 
Gastritis,  acute,  538 
pain  in,  536 
atrophic,  541 
chronic,  540 

distinguished   from    cancer    and 

ulcer,  544 
dry  mouth  in,  456 
in  mitral  incompetency,  434 
weight  in,  64 
due  to  micro-organisms,  540 
mycotic  and  diphtheritic,  539 
in  onset  of  acute  diseases,  539 
paresthesia  in,  34 
phlegmonous,  539 
sympathetic,  539 
toxic,  539 
vomiting  in,  531 
Gastro-diaphony,  510 
Gastrodynia,  535 
Gastroxynsis,  553 
Gerhardt,  complemental  space  of,  236 

sign  of  cavity,  273 
Gibbes'  solution  for  tubercle-bacilli,  291 
Glanders,  821 

bacillus  of,  169 

distinguished  from  rheumatism,  755 
nasal,  204 
Glands,  lymphatic,  in  general  diagnosis,137 
supra-clavicular,  in  gastric  carci- 
noma, 137 
Glenard's  disease,  610 
Globus  hystericus,  208 
Glossitis,  acute,  465 

chronic  superficial,  466,  469 
dissecting,  466 
hemi-,  465 
Goitre,  exophthalmic,  126,  749 
facies  in,  120 
heart-murmurs  in,  387 
pulse  in,  394,  395 
Gonococcus,  171 
Gout,  759 

abscesses  in,  760 


Gout,  acute  articular,  759 

chronic,  760 

diathesis  of,  55 

distinguished    from     rheumatoid   ar- 
thritis, 758 

dyspepsia  in,  759 

gastric  symptoms  in,  557 

joint  of,  145 

pharyngitis  in,  475 

pyorrhoea  alveolaris  in,  460 

relation  of,  to  lithsemia,  624 

retrocedent,  760 

stomatitis  in,  462 

teeth  in,  460 
Gram's  method,  158,  166 
Graves'  disease,  749  (see  Goitre). 
Gummata,  in  larynx.  225 
Gums,  hemorrhage  from,  305 

in  lead-poisoning,  460 

in  scurvy,  459 


H^MATEMESIS,  528 
Hematocele,  pelvic,  503 
Hematokrit,  732 
Hematoma,  181 

auris,  127 
Hematuria,  causes  of,  686 

due  to  trichomonas,  703 

intermittent,  695 

in  pernicious  malaria,  817 
Hernocytometer,  Gowers',  729 

Thoma-Zeiss',  731 
Hemoglobinometer,  Fleischl's,  729 

Gowers',  728 
Hemoglobinuria,  paroxysmal,  687 
Haemophilia,  181,  765 

conditions  with  which  confounded,  766 

degrees  of,  766 

joint-symptoms  in,  766 
Hemoptysis,  279,  302,  528 

causes  of,  302 

diagnosis  of,  304 

distinguished  from  hematemesis,  305 

in  incipient  tuberculosis,  331,  335 

in  pulmonary  embolism,  319 

in  tuberculosis.  303 

symptoms  of,  304 
Hemothorax,  345 
Hair,  in  diagnosis,  122 

color  of,  123 
Hand,  claw-,  130,  133 

contraction  of  fascia  of,  133 

deformities  of,  130,  131 
Hands,  cold,  136 

in  general  diagnosis,  129 
"  Hanging-drops,"  158 
Hay-fever,  206,  312 
Haygarth's  nodosities,  133 
Headache,  'blind,"  534 

caused  by  carious  teeth,  460 

character  of  pain  in,  909 

chronic,  causes  of,  907 

in  coryza,  906 

divisions  of,  according  to  location,  907 

duration  of,  909 


INDEX. 


921 


Headache  in  early  typhoid,  771 
in  fever,   110 

in  inflammation  of  cranial  bones,  906 
intracranial,  906 
in  lithsemia,  623,  624 
in  middle-ear  disease,  906 
neuralgic,  838,  904 
neurasthenic,  908 
ocular,  905,  908 
organic,  908 
in  scalp  affections,  903 
sympathetic  or  reflex,  904,  905 
in  syphilitic  nodes  of  cranial  bones,  142 
in  systemic  diseases,  905 
ursemic,  709 
Hearing,  in  affectionsof  auditory  nerve,  863 

testing  of,  127 
Heart,  action  of,  353 

alterations  of  rhythm  of,  causes  of,  355 
anatomy  of,  351 

topographical,  351 
aneurism  of,  427 
apex-beat  of,  352,  357 

displaced  to  left,  357 
to  right,  358 
area  of  deep  dulness  of,  364 

method  of  graphic  record  of, 

367 
sense  of  resistance  of,  368 

superficial  or  absolute  dulness  of, 
362 
changes  in  size  of,  363 
arrhythmia  of,  411 
auricles  of,  hypertrophy  of,  439,  440, 

441 
auscultation  of,  368 
bovine,  428 
-burn,  553 

cantering  rhythm  of,  375,  443 
chronic  valvular  disease  of,  428 
combined  valvular  lesions  of,  438 
dilatation  of,  441 

symptoms  of,  442 

in  uraemia,  711 
diseases  of,  changes  in  kidneys  in,  413 

coma  in,  412 
disease  of,  congenital,  443 

convulsions  in,  412 

cough  in,  412 

cyanosis  in,  73 

decubitus  in,  58 

dropsy  in,  411 

dyspepsia  in,  412 

dyspnoea  in,  411 

embolism  in,  412 

feebleness  of  aortic  sound  in,  374 
of  mitral  sound  in,  374 
of  pulmonary  sound  in,  375 

friction-sounds  in,  377 

general  symptomatology  of,  353 

hemorrhage  in,  411 

inspection  of  praecordia  in,  356 

pain  in,  407 

palpation  in,  360 

percussion  in,  362 

pleximetric  percussion  in,  365 


Heart,  diseases  of,  pulinonarv  hemorrhage 
in,  303 

pulsation  of  arteries  in,  411 

pulse-tracings  in,  398 

renal  disease  in,  711 

rhythmical   retraction   of    inter- 
spaces in,  360 

thrills  in,  361 

throat-symptoms  in,  413 

thrombosis  in,  412 

valvular,  gastric  catarrh  in,  556 
fatty  degeneration  of,  427 

overgrowth  of,  427 
fibroid  atrophy  of,  427 
foetal  rhythm  of,  375,  443 
hypertrophy  of,  in  arterial  sclerosis, 
444 

causes  of,  438 

diagnosis  of,  441 

pulse  in,  440 

symptoms  and  physical  signs  of, 
439 

in  uraemia,  711 
inflammation  of  muscles  of,  426 

symptoms  of,  184 
impulse  of,  357 

absent,  359 

changes  in  position  of,  357 

character  and  strength  of,  360 

extent  of,  359 

new  areas  of,  359 
murmurs,  of  anaemia,  385 

areas  of,  370 

cardio-muscular,  386 
-respiratory,  386 

causes  of,  378 

character  of,  369,  384 

classes  of,  379 

diagnosis  of,  379. 

direction  of  transmission  of,  369, 
372,  380,  383 

disappearance  of,  385 

distinguished  from  normal  sounds 
of,  384 
from  pericardial  friction,  415 

due  to  incompetency,  385 

functional,  not  anaemic,  3S6 

hsemic  or  functional,  379 

of  mitral  obstruction,  385 

multiple,  388 

nature  of.  380 

outline  of,  on  chest-wall,  351 

position  of  maximum  intensity  of, 
369,  372,  3S0 

seats  of,  379 

significance  of,  386 

in  simple  endocarditis,  422 

time  of,  381 
pain  in  disease  of,  408 
palpitation  of,  408.  410 

in  Graves'  disease,  749 

in  gastric  diseases,  537 

in  lithaemia,  624 
right  ventricle  of,  hypertrophy  of,  439, 

440 
rupture  of,  427 


922 


INDEX. 


Heart-sounds,  abnormal,  377 
all  increased,  372 
all  weakened,  372 
differentiation  of,  371,  372 
false  reduplication  of,  377 
in  health,  368 
individual  changes  in,  372 
reduplication  of,  375,  376 
valves  of,  position  of,  352 

shock  of,  361 
valvular  disease  of,  pain  in,  409 
pulmonary,  437 
secondary  effect  on  heart  and 
pulse  in,  387 
Heberden's  nodes,  133 
Hectic  fever,  91 
Heel,  pain  in,  45 
Hemianopia,  856 

Wernicke's  sign  of,  857 
Hemicrania,  906 
Hemiplegia  after  measles,  792 
in  capsular  lesions,  849 
gait  in,  60 
infantile,  889 
nails  in,  136 
pontine,  850 
uremic,  710 
Hemorrhage,  180 
in  ansemia,  76 
in  aortic  aneurism,  448 
in  cardiac  disease,  411 
cerebral,  886 

laryngeal  symptoms  in,  226 
restlessness  in,  59 
in  cirrhosis  of  liver,  643 
due  to  drugs,  77 

external,  in  aortic  aneurism,  449 
gastric,  527 
in  gastric  ulcer,  545 
intestinal,  569 
in  jaundice,  629 
in  leucocythsemia,  743,  746 
meningeal,  871,  888 
in  mouth,  456 
pulmonary,  302 

without  known  cause,  304 
symptoms  and  diagnosis  of,  304 
in  pulmonary  tuberculosis,  331,  335 
scorbutic,  762 
into  skin,  75 
in  splenic  leukaemia,  660 
symptoms  of,  181 
toxic,  77 
uremic,  712 
Hemorrhoids,   diagnostic   significance   of, 

612 
Heredity  of  diseases,  27 
Herpes  of  fifth  nerve,  83 

distinguished  from   erysipe- 
las, 83 
labialis  or  facialis,  83 
zoster,  82 

abdominal  pain  in,  495 

in  connective-tissue  dystrophies, 

99 
distinguished  from  erysipelas,  807 


Hiccough  in  gastric  diseases,  537 

Histories  of  cases,  plan  for  keeping,  21,  22 

Hodgkin's  disease,  746 

Haemophilia,  77 

Hunger,  deviations  in,  550 

Hydatid  disease  of  lungs,  340 

Hydrocephalus,  124,  125 

chronic,  894 
Hydronephrosis,  672,  722 

distinguished   from    hydatid   disease, 
651 

intermittent,  722 
Hydrophobia,  825 
Hydrothorax,  345 
Hyperemia  or  congestion,  177 

arterial,  177 

causes  and  symptoms  of,  177 

neuro-paralytic,  178 

neuro-tonic,  178 

venous  or  chronic,  178 
Hyperesthesia,  835 
Hyperorexia,  550 
Hypochondriasis,  in  gastric  neuroses,  549 

oxaluria  in,  707 
Hysteria,  900 

angina  pectoris  in,  410 

attacks  of,  902 

cough  in,  300 

diagnosis  of,  37 

distinguished  from  meningitis,  885 

eyes  in,  862 

gastralgia  in,  552 

gastric  symptoms  in,  549 

joint  of,  146 

membranous  enteritis  in,  567 

"phantom  tumor  in,"  498 

postures  in,  59 

simulated  peritonitis  in,  615 

spasm  of  oesophagus  in,  492 

vision  in,  855 
Hystero-epilepsy,  902 


IMPETIGO,  distinguished  from  chicken- 
pox,  790 
Indicanuria,  690 

in  empyema,  345 
in  peritonitis,  614 
Indigestion  in  adenoids  of  nasopharynx, 
484  _ 
chronic,  in  lithsemia,  623 
intestinal,  582 
Influenza,  799 

bacillus  of,  292 
fatigue  in,  34 
Infarct,  hemorrhagic,  180 
Inflammation,  symptoms  of,  183 

in  various  structures,  184 
Infant,  yellow  skin  in,  71 
Inspection,  general  discussion  of,  51 
Intestines,  accumulation  of  gas  in,  497 
acute  catarrh  of,  583 
varieties  of,  585 
amyloid  degeneration  of,  609 
arteries  of,  emboli  in,  560 
cancer  of,  609 


INDEX. 


923 


Intestines,  cancer  of,  obstruction  in,  597 
catarrh  of,  564 
chronic  catarrh  of,  566,  592 
diseases  of,  558 

constipation  in,  567 
diarrhoea  in,  563 
in  other  affections,  559 
physical  signs  in,  569 
embolism  of,  180 
hemorrhage  in,  569 
ileo-csecal  valve  of,  cancer  of,  503 
intussusception  of,  503,  595,  600 
obstruction  of,  acute,  594 
causes  of,  595 

differential  diagnosis  in,  598 
seat  of,  599 
symptoms  of;  596 
chronic,  597 
diagnosis  of,  601 
distinguished  from  colic,  563 

from   hemorrhagic   pancrea- 
titis, 663 
from  peritonitis,  615 
indicanuria  in,  600 
tuberculosis  of,  608 
'  ulceration  of,  593 
volvulus  of,  595,  601 
worms  in,  symptoms  of,  559 
Intussusception,  503,  595,  600 
Iridoplegia,  859 
Iris,  actions  of,  859 

paralysis  of,  859 
Itching  in  skin  eruptions,  80 


"JAUNDICE,  acute  febrile,  633 
*J     catarrhal,  652 

due  to  shock  or  emotions,  631 
hsematogenons,  629 

distinguished  from  hepatogenous, 
631 
hemorrhage  in,  77 
hepatogenous,  630 
infantile,  631 
malignant,  631 

of  hypertrophic  cirrhosis,  632 
pulse  in,  395 
skin  in,  71,  74 
symptoms  of,  72,  629 
Joints,  affections  of,  distribution  in,  143, 
148 
subjective  symptoms  in,  144 
diagnostically  important,  143,  147 
enlarged,  general  causes  of,  143 
examination  of,  147 
hysterical,  146,  901 
tabetic,  146 

trophic,  distinguished  from  rheuma- 
tism, 755 


KIDNEY  or  kidneys  (see  also  Urine  and 
Nephritis), 
abscess  of,  671,  672,  720 

around,  723 
abscesses  of,  multiple,  pus-casts  in,  699 


Kidney,  amyloid  degeneration  of,  720 
calculi  in,  722 
congestion  of,  713 
cystic,  175,  721 

diseases  of,  classification  of,  668 
face  and  skin  in,  712 
frequency  of  micturition  in,  66& 
gastric  symptoms  in,  557 
pain  in,  668 
uraemia  in,  709 
enlargement  of,  causes  of,  671 

diagnosis  of,  672 
left,    enlargement    of,    distinguished 

from  enlarged  spleen,  659 
examination    of,    by    special    instru- 
ments, 673 
floating,   confounded    with    enlarged 
gall-bladder,  655 
Dietl's  crises  in,  669 
palpation  of,  671,  673 
granular  or  cirrhotic,  717 
horseshoe,  722 
hydatid  cyst  of,  672 
inflammations  of,  713 
morbid  processes  in,  667 

symptoms  of,  667,  668 
movable  or  floating,  724 

distinguished  from  tumor  of 
gall-bladder,  726 
neuralgia  of,  669 
palpation  and  percussion  of,  670 
parasites  in,  724 

passive  congestion  of,  in  cardiac  dis- 
ease, 413 
sarcoma  and  carcinoma  of,  721 
tumors  of,  671 

distinguished  from  enlarged  liver, 

639 
malignant,  673 
Koch-Ehrlich  (aniline  solution),  158 
stain  for  tubercle-bacilli,  289 


T  AGOPHTHALMOS,  126 
Jj  Landry's  paralysis,  876 
Laryngismus  stridulus,  217,  219,  865 

in  rhachitis,  761 
Laryngitis,  acute,  2l4,  217 

differential  diagnosis  of  various 

forms  of,  217 
with  spasms,  216,  217 
with  stenosis,  214,  217 
submucous,  21S 
chronic,  218 
membranous,  217 
phlegmonous,  218 
sicca,  215 

spasmodic,  distinguished  from   bron- 
chitis, 308 
Laryngoscopy,  212 

Larynx,  in  affections  of  tenth  nerve,  864 
anesmia  of,  214 
appearance  of,  in  health,  213 
diseases  of,  laryngoscopy  in,  212 

secondary  to   general    affections, 
207 


924 


INDEX. 


Larynx,  diseases  of,  symptoms  in,  206-211 
foreign  bodies  in,  226 
hyperemia  of,  214 
inflammations  of,  214 
leprosy  of,  225 
lupus  of,  225 

muscles  of,  paralyses  of,  220 
neuroses  of,  219 
in  nervous  diseases,  226 
oedema  of,  216,  217. 
perichondritis  of,  218 
syphilis  of,  224 
tuberculosis  of,  222 
tumors  of,  221 
Laughing,  forced,  in  multiple  sclerosis,  892 
Lead-Doisoning,  gums  in,  460 

wrist-drop  in,  131 
Leprosy,  826 

bacillus  of,  J  70 
of  mouth,  463 
laryngeal,  226 
Leptomeningitis,  cerebral,  883 

spinal,  869 
Leucocytes,  Neusser's  granules  in,  733 

varieties  of,  727 
Leucocythaemia,  acute,  746 
blood  in,  744 

cover-glass  preparations  of,  744 
methods  of  staining,  744 
diagnosis  of,  745 

distinguished  from  Hodgkin's  disease, 
744,  748 
from  leucocytosis,  744 
duration  of,  746 
liver  in,  744 
lymphatic  form  of,  745 
spleno-medullary  form  of,  743 
varieties  of  leucocytes  in,  744 
Leucocytosis,  diagnostic  value  of,  733 
pathological,  732 
physiological,  732 
Leukaemia,  743 
acute,  746 
pseudo,  746 
splenic,  660 
Lipaemia,  733 
Lipuria,  702 
Lips,  in  diagnosis,  125 
Lithaemia,  acute  and  chronic,  623 

gouty  aspect  in,  624 
Liver  (see  also  Jaundice), 
abscess  of,  634,  646 

in  amoebic  dysentery,  591 
atypical  cases  of,  648 
diagnosis  of,  648 
distinguished  from  cancer,  641 
empyema  in,  649 
exploratory  puncture  in,  649 
physical  examination  in,  647 
pyaemia  in,  649 

pylephlebetic  and  pyaemic,  649 
sputum  in,  280 
symptoms  of,  647 
acute  yellow  atrophy  of,  631 

cerebral    symptoms    in, 
629 


Liver,   acute    yellow   atrophy   of,    distin- 
guished from  Weil's  disease,  633 
amyloid  disease  of,  634,  640 
cancer  of,  640 

conditions      with     which      con- 
founded, 641 

diagnosis  of,  641 

fever  in,  633 

palpation  in,  634 

symptoms  of,  640 
cirrhosis  of,  642 

abdominal  veins  in,  404 

atrophic,  642 

collateral  circulation  in,  644 

diagnosis  of,  645 

duration  of,  644 

fatty,  639,  645 

hemorrhage  in,  643 

hypertrophic  or  biliary,  642,  645 
distinguished    from    cancer, 
641 

syphilitic,  645 

venous  hum  in,  406 
congestion  of,  622,  625 
constriction  of,  from  lacing,  635 
diseases  of,  age  and  sex  in,  627 

auscultation  of,  636 

fever  in,  632 

gastric  symptoms  in,  557 

habits  in,  628 

hemorrhage  in,  626 

inspection  in,  629 

jaundice  in,  629 

pain  in,  42,  628 

palpation  in,  633 

percussion  in,  636 

previous  disease  in,  628 

syphilitic,  645 
enlargement  of,  causes  of,  637 

conditions  with  which  confounded, 
637 

pain  in,  639 

simulated,  637 
exploratory  puncture  of,  636 
fatty,  634,  639 
floating,  635 

functional  disturbance  of,  622 
hydatid  disease  of,  650 

distinguished    from    cancer, 
642 

tumor  of,  634 
melanotic  sarcoma  of,  640 
morbid  processes  in,  622 
nutmeg,  642 
obstruction  of  channels  of,  625 

collateral  circulation  in,  627 
symptoms  in,  625,  626 
pulsation  of,  635 

in  tricuspid  regurgitation,  437 
in  suppuration  of  portal  vein,  626 
syphilitic,  distinguished  from  cancer, 
641 

gummata  in,  646 
in  thrombosis  of  portal  vein,  626 
topographical  anatomy  of,  628 
Locality,  sense  of,  835 


INDEX. 


925 


Locomotor  ataxia,  876 
crises  in,  43 
gait  in,  60 

gastric  symptoms  in,  557 
joint  of,  distinguished  from  rheu- 
matoid arthritis,  759 
laryngeal  symptoms  in,  226 
pulse  in,  395 
station  in,  61 
trophic  joint  of,  146 
Lumbago,  756 

Lungs  or  lung,  abscess  of,  338 
actinomycosis  of,  821 
active  congestion  of,  317 
affections  of,  228 

distinguished  from  pleural  affec- 
tions, 277 
cancer  of,  339 
capacity  of,  276 
cavities  of,  273 
cough  in,  302 
hemorrhage  in,  304 
cavity  in,   distinguished   from  pneu- 
mothorax, 350 
collapse  of,  338 
diseases  of,  hemorrhage  in,  302 

pain  in,  305 
embolism  of,  180 

and  thrombosis  of,  318 
gangrene  of,  337 
in  diabetes,  764 

distinguished   from   foetid    bron- 
chitis, 311 
hemorrhage    from,    without    known 

cause,  304 
hemorrhagic  infarct  of,  319 
hydatid  disease  of,  340 
oedema  of,  318 
passive  congestion  of,  318 
and  pleurae,  diseases  of,  228 

differential  diagnosis  in,  231 
dyspnoea  in,  293 
without  dyspnoea,  293 
inspection  and  palpation  in, 

232 
relation  of  heart  to,  230 

infectious  diseases  to,  231 
relative   value  of  subjective 
and  objective  symptoms  in, 
231 
table  of,  228 

symptoms  of,  due  to  external 
causes,  230 
svmptoms  due  to  morbid  processes 
in,  229 
size  of,  determined  by  percussion,  257 
symptoms  due  to  obstruction  of,  229 
topographical  anatomy  of,  235 
Lupus,  laryngeal,  225 
Lymph-adenoma,  746 
Lymphangitis,  138 


MACROGLOSSIA,  469 
Main-en-griffe,  130,  133 
Malaria,  811  (see  also  Fever). 


Malaria,  anaemia  in,  738 
cachexia  of,  818 
chronic,  spleen  in,  660 
facies  in,  120 
intermittent,  811 

conditions  with  which  confounded, 

814 
irregular  forms  of,  813 
pernicious,  817 
Plasmodia  of,  735 
cuts  of,  815 
forms  of,  736 
method  of  staining,  737 
remittent,  816 
Marasmus,  62 
Measles,  790 

bronchitis  in,  308 

distinguished  from  scarlatina,  795 

from  variola,  788 
eruption  in  mouth  in,  456 
pharynx  in,  476 
Mediastinum,  cancer  of,  distinguished  from 
aortic  aneurism,  452,  453 
inflammation  of,  453 
tumors  of,  453,  454 

of  pleural  origin,  454 
Medulla  oblongata,  diseases  of,  852 
Megalo-cephalie,  65 
Mebena,  565,  569 
Melanasmia,  733 
Melanuria,  709 

Membranes,  mucous,  symptoms  in  inflam- 
mation of,  184 
serous,  symptoms  in  inflammation  of, 
184  _ 
Meniere's  disease,  61,  863 
Meninges,  diseases  of,  pain  in,  47 

hemorrhage  into,  871,  888 
Meningitis,  aspiration  of  vertebral  canal 
in,  165 
cerebral,  acute,  883 
chronic,  885 
purulent,  885 
syphilitic,  885 
tubercular,  884 
cerebro-spinal,  decubitus  in,  58,  59 

distinguished  from  influenza, 
800 
herpes  in,  83 
distinguished  from  typhoid,  781 
spinal,  chronic,  869,  870 

conditions  from  which  to  be  dis- 
tinguished, 870 
external,  868 
internal,  869 
syphilitic,  870 
tubercular,  distinguished  from  simple, 
884 
Menopause,  paresthesia  in,  34 
Merycismus,  554 
Metallic  tinkling,  271 

in  pneumothorax,  349 
Micrococci,  152 

pigment-production  of,  152 
staining  of,  166 
Micrococcus  lanceolatus,  cultivation  of,  292 


926 


INDEX. 


Micrococcus  lanceolatus,  diseases  in  which 
found,  292 
in  empyema,  166,  171,  173 
inoculation  of,  292 
in  mouth,  457 
in  ozaena,  200 
in  sputum  of  capillary  bronchitis, 

309 
staining  of,  292 
Microcythsemia,  733 

Micro-organism  (see  Bacteria  or  Bacteri- 
ology). 
Micturition,  frequent,  causes  of,  669 
Migraine,  906 
Miliaria,  86 

Milk-leg,  distinguished  from  rheumatism, 
754 
-sickness,  827 
Mitral  incompetency,  431 

accentuation  of  pulmonary  second 

sound  in,  374 
bloodvessels  in,  434 
broken   compensation   in,   symp- 
toms of,  432 
diagnosis  of,  434 
dropsy  in,  411 

effects  of,  on  the  general  circula- 
tion, 431 
murmurs  in,  433 
physical  signs  of,  433 
secondary  changes  in  circulation 

in,  387 
thrill  in,  362 

without  valvular  disease,  432 
pulse-tracing  in,  400 
stenosis,  434 

accentuation  of  pulmonary  second 

sound  in,  374 
associate  murmurs  in,  436 
embolism  in,  435 
murmur  of,  385,  435 
physical  signs  of,  435 
presystolic  thrill  in,  361 
pulse  in,  395,  436 

-tracing  in,  400,  401 
secondary  changes  in  circulation 

in,  388 
thrill  in,  435 
Monoplegia,  uraemic,  710 
Morbid  processes,  176 

symptomatology  of,  176 
in  tubes  or  channels,  189 
Morphinism,  pain  in,  37,  44 
Motility,  disturbances  of,  838 
Mouth,  diseases  of,  455 

objective  symptoms  in,  456 
subjective  symptoms  in,  455 
dry,  455 

eruptions  in,  in  infectious  diseases,  456 
inflammation  of  (see  Stomatitis), 
micro-organisms  in,  457 
secretions  of,  456  (see  also  Saliva), 
scleroderma  of,  464 
ulcers  of,  herpetic,  463 
syphilitic,  463 
Mucous  patches  in  larynx,  225 


Mumps,  800 
face  in,  122 

submaxillary  glands  in,  801 
Murmur  (see  also  Heart), 
anaemic,  385 

in  hemorrhage,  182 
in  aortic  aneurism,  451 
arterial,  401 
brain-,  402 

cardiac  and  vascular,  378 
in  disease  of  arteries,  402 
double,  in  crural  artery,  401 
functional,  386 
haemic,  402 

heard  over  fontanelles,  401 
pressure,  in  arteries,  401,  402 
presystolic,  not  due  to  valvulitis,  436 
Muscles,  atrophy  of,  138 

diagnostic  features  of,  140 

idiopathic,  881 

infantile  form  of,  139 

juvenile  form  of,  139 

peritoneal  type  of,  139 

primary,  139 

progressive  neural,  140 

pseudo-hypertrophic ,  139 

Raymond's  table  of,  140 
hypertrophy  of,  141 
inflammation  of,  141 
ocular,  spasms  of,  861 
paradoxical  contractions  of,  840 
progressive  ossification  of,  142 
pseudo-hypertrophy  of,  880 
Myalgia,  occipital,  904 
of  phthisis,  305 
thoracic,  407 
Myelitis,  acute  transverse,  872 
central,  874 
chronic,  874 

anterior,  claw-hand  in,  130 
disseminated,  873 
Myocarditis,  426 
chronic,  427 
Myositis,  141 
Myotonia  congenita,  141 
Myxoedema,  97 


"VTAILS,  shape  and  color  of,  135 
li     trophic  changes  in,  136 

white  marks  on,  135 
Naso-pharynx,  adenoid  vegetations  of,  483 
Neck,  in  general  diagnosis,  128 
Necrosis,  185 

Nephritis   (see   also  Kidneys,  Urine,   and 
Uraemia), 
acute  exudative  or  glomerulo-,  714 
with  excessive  pus,  715 
"productive  or  diffuse,  715 
anaemia  in,  712 
backache  in,  48 

chronic,  acute  laryngitis  in,  214 
eruptions  in,  86 

productive   or  diffuse,  with  exu- 
dation, 715 
without  exudation,  717 


INDEX. 


927 


Nephritis,  chronic,  rhinitis  in,  194 
skin  in,  71 
classification  of,  713 
facies  in,  120 

gastro-intestinal  symptoms  in,  713 
interstitial,  717 
cedema  in,  causes  of,  97 
pulmonary  complications  in,  713 
suppurative,  720 
in  tonsillitis,  481 
tubercular,  720 
Nephrolithiasis,  722  _ 
Nerves  or  nerve,  auditory,  diseases  of,  863 
cervical   sympathetic,  hypersernia   in 

diseases  of,  178 
diseases  of  seventh,  121 
facial,  diseases  of,  862 
fifth,  diseases  of,  860 

disease  of,  hypersernia  in,  178 
herpes  of,  83 
fourth,  diseases  of,  860 
glosso-pharyngeal,  diseases  of,  864 
oculomotor,  in  lesions   of  crus  cere- 
bri, 850 
diseases  of,  859 
olfactory,  diseases  of,  853 
optic,  diseases  of,  855 
pneumogastric,  diseases  of,  864 
recurrent   laryngeal,  in  aortic  aneu- 
rism, 448 
paralysis  of,  221 
sixth,  diseases  of,  861 
spinal,  diseases  of,  866 

accessory,  diseases  of,  865 
supplying  larynx,  paralysis  of,  220 
sympathetic,   pressure   on,   iu    aortic 

aneurism,  448 
twelfth,  diseases  of,  866 
Neuralgia,  837 

abdominal,  495,  563 
caused  by  carious  teeth,  460 
causes  of,  837 
cephalic,  904 
in  diabetes,  765 
infraorbital,  861 
intercostal,  407 

distinguished  from  pleurisy,  305, 
348 
of  kidneys,  669 
malarial^,814 
in  nephritis,  669 
ocular,  861 
seats  of,  837 
supraorbital,  861 
syphilitic,  905 
tender  points  in,  43 
trifacial,  837,  861 
vasomotor,  837 
Neurasthenia,  903 
gastralgia  in,  551 
gastric,  554 

symptoms  in,  549 
in  Glenard's  disease,  611 
headache,  908 
spinal,  903 
Neuritis  of  circumflex,  147 


Neuritis,  commonest  seats  of,  867 
hemorrhage  in,  77 
in  leprosy,  826 
multiple,  868 
nails  in,  136 
optic,  856 

in  meningitis,  883 
peripheral,  in  diabetes,  764 
of  spinal  nerves,  866 
Night-blindness,  855 

in  scurvy,  763 
Night-sweats,  in  tuberculosis,  335 
Nigrities,  465 
Nodules,  subcutaneous,  100 
Nose,  in  adenoids  of  nasopharynx,  484 
auxiliary  cavities  of,  diseases  of,  205 
catarrhs  of,  200 
diseases  of  (see  also  Rhinitis), 
asthma  in,  206,  194,  296 
color  of    mucous    membrane   in, 

198 
epistaxis  in,  200 
hay-fever  in,  206 
microscopical  examination  of  se- 
cretions in,  199 
mouth-breathing  in,  200 
palpation  in,  198 
rhinoscopy  in,  196 
secretions  in,  199 
symptomatic  of  general  affections, 

194 
symptoms  of,  193 
subjective,  194 
objective,  195 
ulceration  of  mucous  membrane 

in,  199 
ulcerative,  205 
foreign  bodies  in,  204 
glanders  in,  204 
hypertrophies  in,  202  . 
nerves  of,  194 
polypi  of,  198,  203 
tumors  of,  204 
Nyctalopia,  855 
Nystagmus,  860,  879 


OCCUPATION,  56 
CEdema,  angio-neurotic,  96 
of  arms  and  thorax,  95 
causes  of,  92 

combined,  97 
conditions   with   which   con- 
founded, 94 
definition  of,  92 
of  face,  96 
of  feet,  95 
general,  96 

of  larynx,  in  angio-neurotic  oede- 
ma, 97 
local,  94 

diagnostic  significance  of,  96 
pulmonary,  318 
recognition  of,  93 
renal,  712 
temporary  disappearance  of,  94 


928 


INDEX. 


(Esophagus,  absence  of,  490 

acute  inflammation  of,  490 

cancer  of,  distinguished  from  aortic 
aneurism,  452 
symptoms  in,  189 

carcinoma  of,  490 

chronic  inflammation  of,  490 

dilatation  of,  492 

diseases  of,  487 

functional,  492 

foreign  bodies  in,  491 

hemorrhage  from,  487 

method  of  passing  bougie  into,  488 

normal  constriction  of,  488 

obstruction  of,  489 

paralysis  of,  492 

spasm  of,  492 

stricture  of,  490 
Oligemia,  177 
Oligochromemia,  732 
Oligocythemia,  732,  741 
Ophthalmoplegia,  861 
Opisthotonos,  59 
Opium-poisoning,  saliva  in,  458 
Orthopnoea,  59 
Osteitis  deformans,  66 
Osteo-arthropathy,  pulmonary,  67 
Osteomalacia,  68 
Osteomyelitis,  143 
Ovary,  cysts  of,  fluid  of,  174 

tumors  of,  504 
Oxaluria,  706 

a  cause  of  cyclical  albuminuria,  685 
Ozena,  203 

in  glanders,  821 

PACHYMENINGITIS,  cerebral,  883 
cervical  hypertrophic,  870 
spinal,  868 

distinguished  from  myelitis,  875 
Pain,  abdominal,  character  and  mode  of 
onset  of,  495 

uremic,  710 

in  vertebral  disease,  42,  495 
in  angina  pectoris,  409 
in  aortic  aneurism,  448 
cardiac,  in  lithemia,  624 

region,  causes  of,  407 
character  of,  40 
chest,  in  tuberculosis,  335 
clinical  value  of,  3S 
constant  and  temporary,  39 
crises  of,  43 
definition  of,  35 
diagnostic  value  of,  in  enlarged  liver, 

639 
in  diaphragmatic  pleurisy,  346 
in  disease  of  abdominal  walls,  495 

of  the  aorta,  408 

of  heart,  408 

of  mouth,  455 

of  pericardium,  408 
in  epigastrium,  407 
estimation  of  degree  of,  38 
in  extrauterine  pregnancy,  562 


Pain  in  the  extremities,  44 

forerunner  of  apoplexy,  45 
facial  expression  in,  35 
in  gastric  affections,  534,  562 

ulcer,  407,  545 
general  and  local,  41 
in  girdle-sensation,  46 
in  head,  903 
in  hepatic  disease,  628 
inflammatory,  183 

influence  of  mental  association  in,  36 
in  joint-affections,  144 
in  kidney  disease,  668 
in  laryngeal  affections,  207 
in  legs  in  tuberculosis,  332 
location  of,  41 
in  the  loins,  48 
in  meningeal  diseases,  47 
methods   of   recognizing   objectively, 

35 
modes  of  onset  of,  39 
modified  bv  pressure,  movement,  rest, 

43 
in  Morton's  painful  affection  of  the 

foot,  45 
in  muscular  rheumatism,  756 
in  nasal  affections,  194 
objective  investigation  of,  37 
over  frontal  sinus,  195 
pancreatic,  562 
paroxysmal  and  periodic,  40 
pathology  of,  35 

peripheral,  of  central  origin,  43 
in  pharyngeal  affections,  480 
in  pleurisy,  341,  346 

distinguished   from   other  chest- 
pains,  305 
post-sternal,  46 
posture  in,  36 
in  Pott's  disease,  143 
power  of  inhibiting,  37 
precordial,  due  to  aneurism,  408 
in  pulmonary  disease,  305 
rectal,  562 

reflex  actions  due  to,  36 
sensation  of,  836 
in  the  side,  47 
simulated,  37 

sources  of  error  in  estimating,  36 
in  spinal  curvature,  47 
in  spine,  46 

superficial  and  deep-seated,  41 
sympathetic  or  reflex,  definition  of,  35^ 

42 
in  tabes  dorsalis,  877 
time  of  occurrence  of,  40 
in  toxemias,  41 
in  valvular  heart  disease,  409 
variations  of,  in  disease,  35 
Palpation,  general  discussion  of,  52 
Pancreas,  affections  of,  pain  in,  535 

cancer  of,  distinguished  from  hepatic 

cancer,  642 
cyst  of,  175,  665 

distinguished  from  enlarged  liver, 
639 


INDEX. 


929 


Pancreas,  diseases  of,  pain  in,  562 
symptoms  in,  661 
hemorrhage  into,  662 
tumors  of,  505,  661,  663 

distinguished  from  aneurism,  662 
Pancreatitis,  acute  hemorrhagic,  663 
chronic,  665 
gangrenous,  664 

hemorrhagic,  distinguished  from  in- 
testinal obstruction,  602 
suppurative,  664 
Papilloma  of  larynx,  222 
Paresthesia,  34,  835 
in  lithsemia,  624 
Paralysis,  838 

acute  ascending  or  Landry's,  876 
agitans,  895 

distinguished  from  multiple  scle- 
rosis, 893 
face  in,  121 
gait  in,  60 
alternating,  850 
Bell's,  862 

bulbar,  laryngeal  symptoms  in,  226 
causes  of,  838 
divers',  876 

general,  of  insane,  face  in,  121 
glosso-labial,  121 

face  in,  121 
-laryngeal  or  bulbar,  893 
hysterical,  901 
pseudo-hypertrophic  muscular,  880 

spinal  curvature  in,  61 
symptoms  of,  838 
vasomotor,  841 
Paramoecium  coli,  576 
Paramyoclonus  multiplex,  141 
Paraplegia,  ataxic,  879 
hereditary,  869 
of  divers,  876 

hysterical,  distinguished  from  chronic 
myelitis,  874 
gait  in,  60 
primary  spastic,  878 
spastic,  cross-legged  progression  in,  61 
gait  in,  60 
Parasites,  151 
Paresis,  838 
Parotitis,  486 

epidemic,  800 
Pectorilocpjy,  272 
Peliosis  rheumatica,  768 
Pelvis,  abscess  of,  503 

hematocele  of,  503 
Peptonuria,  685 
Percussion,  252  {see  also  Chest). 

auscultatory,  in  aortic  aneurism,  451 

in  dilated  stomach,  547 
general  discussion  of,  53 
Pericarditis,  413 

acute  fibrinous  or  plastic,  414 
causes  of,  414 
chronic  adhesive,  420 
friction  in,  362 

-sound  in,  415 
in  general  diseases,  414 


Pericarditis,  mediastino-,  indurative,  421 
pain  in,  408 
purulent,  416 
in  rheumatic  fever,  753 
tuberculous,  416 
with  effusion,  416 

Bamberger's  sign  in,  419 

diagnosis  of,  419 

early   dulness    in   cardio-hepatic 

triangle  in,  418 
local  symptoms  in,  416 
physical  signs  of,  417 
Pericardium,  adherent,  420 

Friedreich's  sign  in,  420 
pulsus  paradoxus  in,  420 
presystolic  murmur  in,  436 
aspiration  of,  164 
diseases  of,  decubitus  in,  58 
facies  in,  58 
friction-sounds  in,  377 
pain  in,  408 
effusion  into,  distinguished  from  en- 
larged liver,  638 
hsemo-,  420 
hydro-,  419 
inflammation  of,  413 
pneumo-,  420 
Perinephritis,  672 

Periostitis,   distinguished   from    rheuma- 
tism, 754 
Peritoneum,  cancer  of,  618 
pneumo-,  613 
tubei-culosis  of,  618 

confounded    with    appendicitis, 

619 
diagnosis  of,  621 
with  effusion,  620 
with  tumors,  620 
without  effusion  and  tumors,  621 
Peritonitis,  612 

abdominal  walls  in,  501 
acute  tubercular,  distinguished  from 
appendicitis,  608 
swelling  in  pubic  region  in, 
505 
in  amoebic  dysentery,  591 
ascites  in,  617 

bacillus  coli  communis  in,  579 
causes  of,  613 
chronic,  616 

conditions  with  which  confounded, 615 
decubitus  in,  58 
diagnosis  of,  615 
due  to  streptococci,  613 
facies  in,  120 
hysterical,  615 

intestinal  obstruction  in,  560 
local  circumscribed,  616 

distinguished  from  colic,  561,  563 
physical  examination  in,  613 
symptoms  of,  613,  614 
tubercular,  616 

perihepatitis  in,  621 
vomiting  in,  532 
Perityphlitis,  607 
Perspiration,  diminished,  91 

59 


930 


INDEX. 


Perspiration,     increased,     conditions     in 
which  it  may  occur,  90 
local,  91 
Pertussis,  217,  798 
cough  in,  302 
Petri's  plates,  161 
Pharyngitis,  acute,  485 
chronic,  486 
in  lithsemia,  623 
phlegmonous,  485 
rheumatic,  486 
in  scarlatina,  796 
Pharynx,  adenoids  of,  bleeding  points  in, 
477 
anaesthesia  of,  479 
diseases  of,  475 

enlargement  of  cervical  glands  in, 

479 
subjective  symptoms  in,  480 
eruptions  on,  477 
examination  of,  477 
inflammations  of,  485 
naso-,  in  children,  476 
retro-,  abscess  of,  486 
spasm  of,  480 
ulceration  of  478 
Phlegmasia  alba  dolens,  distinguished  from 

rheumatism,  754 
Phosphorus-poisoning,  632 
Phthisis  (see  Tuberculosis). 
Pica,  537 
Plague,  the,  825 
Plasmodia,  of  malaria,  735 
Plethora,  177 
Pleura,  aspiration  of,  164 
diseases  of,  340 
effusion  into,  173 
effusions  into,  decubitus  in,  57 

pulsating,  346 
hemorrhagic  exudation  into,  172 
purulent  effusions  into,  343 
serous  effusions  into,  342 
thickened,  345 

transudation  of  blood  into,  345 
Pleurae,  affections  of,  228,  230 
air  in  lungs  in,  230 
distinguished     from     pulmonary 
affections,  277 
effusion  into,  distinguished  from  en- 
larged liver,  638 
from  hydatid  disease,  652 
fluctuation  in,  251 
movement  of  chest  in,  248 
place  of  pointing  in,  235 
Skodaic  resonance  in,  258 
vocal  fremitus  in,  251 
Pleurisy,  acute,  341 

bronchial  breathing  in,  266 
chronic,  348 

movement  of  chest  in,  248 
with  effusion,  348 
cough  in,  301 
decubitus  in,  57 
diagnostic  features  of,  346 
diaphragmatic,  346 
decubitus  in,  59 


Pleurisy,  diaphragmatic,  pain  in,  42 

diseases    from   which    to    be    distin- 
guished, 347 
distinguished  from  pleurodynia,  249 
dry  or  plastic,  341,  348 
exploratory  puucture  in,  347 
general  causes  of,  341 
pain  in,  305,  407 
of  phthisis,  pain  in,  305 
in  rheumatic  fever,  753 
tuberculous,  345 
Pleurodynia,  407,  756 

distinguished  from  pleurisy,  249,  305, 
347 
Pleximeter,   percussion   with,   in   cardiac 
disease,  365 
re-percussion  with,  367 
Pneumococcus,  166,  171,  173 
Pneumonia,  absence  of  vocal  fremitus  in, 
250 
accentuation    of    pulmonary    second 

sound  in,  374 
in  acute  rheumatism,  753 
aspiration-,  325 
broncho-  or  catarrhal,  325 

distinguished  from  bronchi- 
tis, 307 
from  collapse  of  lung,339 
physical  signs  of,  325 
tuberculous  form  of,  326 
vesicular  breathing  in,  268 
causes  of  dyspnoea  in,  294 
central,  266 
chronic  interstitial,  326 
croupous  or  lobar,  319 

bacteriological  diagnosis  in,  325 

bilious,  324 

central,  320 

cerebral  symptoms  in,  322 

in  children,  aged,  and  drunkards, 

324 
complications  of,  325 
crisis  in,  321,  323 
distinguished  from  bronchitis,  307 
diagnosis  of,  324 
distinguished    from    collapse    of 

lung,  339 
duration  and  course  of,  323 
fever  in,  321 

gastro-intestinal  symptoms  in,  322 
heart  and  pulse  in,  322 
herpes  in,  322 
leucocytosis  in,  322 
migratory,  324 
mode  of  onset  of,  319 
physical  signs  of,  323 
pseudo-crises  in,  321 
-    pulse-respiration,  ratio  in,  320 
respiratory  symptoms  in,  320 
rusty  sputum  of,  321 
sweating  in,  322 
temperature-chart  of,  321 
urine  in,  322 
in  wasting  diseases,  324 
decubitus  in,  57 
distinguished  from  influenza,  800 


INDEX. 


931 


Pneumonia,  distinguished  from  pleurisy, 
347 
from  acute  tuberculosis,  329 

facies  in,  120 

movement  of  chest  in,  249 

myocarditis  in,  426 

respirations  in,  108 

rusty  sputum  of,  303 

simulated    by   phlegmonous   pharyn- 
gitis, 4S5 

Skodaic  resonance  in,  258 

sputum  in,  280 

typhoid,  324 

without  bronchial  breathing,  266 
Pneumonokoniosis,  326,  327 
Pneumoptosis,  553 
Pneumothorax,  348 

amphoric  breathing  in,  267 

cracked-pot  sound  in,  260 

diseases    from   which    to    be    distin- 
guished, 317,  350,  506 

dyspnoea  in,  296 

movement  of  chest  in,  248 

percussion  in,  260 
Poikilocytosis,  733,  741 
Poliomyelitis,  anterior,  875 

chronic,  874,  879 
Polyphagia,  554 
Polvpi,  nasal,  203 
Pons,  lesions  of,  850,  887 
Posture,  in  diagnosis,  57 

in  pain,  36 

prone,  59 
Prfficordia  in  cardiac  disease,  356 
Pregnancy,  pigmentation  in,  74 

vomiting  in,  532 
Pressure,  sense  of,  836 
Proctitis,  585 
Pruritus,  80 

uremic,  710 
Ptomaines,  153 
Ptosis,  860 

morning,  860 
Ptyalism,  463 
Puerperium,  pulse  in,  395 
Pulmonary  insufficiency,  438 

stenosis,  438 
Pulsation,  epigastric,  389 
Pulse  in  aortic  aneurism,  451 

capillary,  390 

in  aortic  incompetency,  430 

Corrigan's  or  water-hammer,  387 

affected  by  condition  of  arterial  walls, 
392 

frequency   of,   diagnostic   significance 
of,  394 
diurnal  variations  in,  391 

intermittent,  394 

irregular,  394 

method  of  taking,  391 

persistently  rapid,  426 

rapid,  causes  of,  394 

in  rheumatoid  arthritis,  752 

rhythm  of,  394 

in  sclerosis  of  artery,  444 

slow,  causes  of,  395 


Pulse,  sphygmographic  tracings  of,  inter- 
pretation of,  398 

tension  of,  high  and  low,  causes  of,  393 

in  the  various  valve-lesions,  387 

venous,  404 

in  tricuspid  incompetency,  405 

volume  of,  393 
Pulsus  paradoxus,  420 
Pupil,  in  aortic  aneurism,  449 

Argyll-Robertson,  859,  877 

in  paralysis  of  iris,  859 
Purpura,  75,  767 

rheumatica,  76 
Pus,  abnormal,  172 

bacteria  in,  166 

chemical  examination  of,  172 

crystals  in,  171 

microscopical  examination  of,  166 

protozoa  in,  171 

sero-,  172 

vermes  in,  171 
Pyemia,  distinguished  from  acute  rheuma- 
tism, 754 

hemorrhage  in,  76 

portal,  626 
Pyelitis,  723 
Pyonephrosis,  672,  723 
Pyo-pneumothorax,  594 

subphrenicus,  350,  506 
Pyrosis,  537,  553 


RALES,  after  exhaustive  fevers,  270 
crackling,  269 

crepitant,  268 

distinguished  from  other  sounds,  269 

dry,  268 

moist,  268 

mucous,  269 

subcrepitant,  269 
Eashes  from  drugs,  84 
Raynaud's  disease,  134 

distinguished  from  purpura,  768 
Rectum,  diseases  of,  612 

fissure  of,  pain  in,  562 

ulcer  of,  pain  in,  42 
Reflexes,  cutaneous,  840 

delay  in,  840 

increased,  841 

patellar,  841 

tendon,  841 
Reichman's  disease,  552 
Resonance,  "bandbox-,"  257 

Skodaic,  258 

in  pleurisy,  342 

percussion,  254 

vocal,  271 
Respiration,  frequency  of,  239 
Retinitis,  albuminuric,  855 
Rhachitis,  67,  761 

brain-murmur  in,  402 

chest  of,  242 

decubitus  in,  58 

distinguished  from  scurvy,  7<il 

laryngismus  stridulus  in,  219 

prsecordia  in,  356,  357 


932 


INDEX. 


Rhachitis,  scurvy-,  763 
Rheumatism,  abdominal,  495,  563 

of  abdominal  walls,  distinguished  from 

peritonitis,  616 
acute  articular,  751 

causes  of,  751 
complications  and  sequelae  of, 

753 
conditions  from  which  to  be 
distinguished,  754 
symptoms  of,  752 
chronic  articular,  755 
diathesis  of,  gastric  symptoms  in,  557 
distinguished  from  acute  glanders,  822 

from  rheumatoid  arthritis,  758 
gonorrhoeal,  joint  of,  145 
muscular,  755 

relation  of,  to  lithsemia,  624 
scarlatinal,  795 , 
subacute  articular,  755 
subcutaneous  nodules  in,  100,  754 
Rheumatoid  arthritis  (see  also  Arthritis), 
756 
acute,  756 
chronic,  757 

conditions  from  which  to  be  dis- 
tinguished, 758 
foot  in,  758 
freckles  in,  75,  757 
Grubler's  tumor  in,  132 
hand  in,  130,  758 
Heberden's  nodes  in,  133 
joint  of,  146 
neuritis  in,  757 
pulse  in,  395,  757 
senile,  758 
skin  of  hand  in,  132 
Rhinitis  (see  also  Nose). 
atrophic,  203' 
caseous,  199 
chronic  hypertrophic,  202 

varieties  of,  201 
sicca,  203 
simple  acute,  200 

diphtheritic  form  of,  201 
Rhinoliths.  204 
Rhinorrhoea,  idiopathic,  206 

strumous,  203 
Rhinoscopy,  196 
Rhonchi,  268 
Ribs,  periostitis  of,  in  prsecordial  region, 

407 
Rickets,  761 
Roseola,  85 
Rubella,  797 

distinguished  from  scarlatina,  796 
Rumination,  554 


SALIVA,  456 
chemical  examination  of,  457 
in  disease,  458 

fungus  of  thrush  in,  458,  459 
leptothrix  buccalis  in,  459 
micro-organisms  in,  457 
microscopic  examination  of,  457 


Saliva,  sugar  in,  458 

sulphocyanide  of  potassium  in,  458 
Salivation,  456,  463 

Salpingitis,  confounded  with  typhoid,  780 
Saprsemia,  151,  185 
Saprophytes,  151 
Sarcinae,  152,  519 

in  urine,  702 
Sarcoma,  of  bones,  distinguished  from  os- 
teomalacia, 68 

laryngeal,  222 

retroperitoneal,  618 

subcutaneous,  100 
Scalp,  affections  of,  pain  in,  903 
Scarlatina,  792  (see  also  Fever). 

anginosa,  795 

pericardial  effusion  in,  420 

pulse  in,  395 
Scars,  138 

significance  of,  in  diagnosis,  92 
Sciatica,  867 

pain  in,  44 

gouty  or  rheumatic,  45 
Scleroderma,  99  • 

of  mouth,  464 
Sclerosis,  amyotrophic  lateral,  879 

laryngeal  symptoms  in,  227 

disseminated  insular,  gait  in,  60 

lateral,  878 

congenital,  878 

multiple  or  insular,  892 
speech  in,  226 

posterior,  laryngeal  symptoms  in,  226, 
876 
Scrofula,  distinguished  from  Hodgkin's  dis- 
ease, 747 
Scurvy,  762 

brawny  induration  in,  99 

gums  in,  459 

hemorrhage  in,  76 

proptosis  in,  126 

-rickets,  763 
Seitz'  sign  of  cavity,  274 
Sensation,  delayed  conduction  of,  836 
Sense,  muscular,  836 
Sensibility,  disturbance  of,  835 

tactile,  835 
Septicaemia,    distinguished    from    miliary 

tuberculosis,  330 
Shock,  119 

from  hemorrhage  distinguished  from 
concussion,  182 

pain  in,  37,  38 

perspiration  in,  90 

restlessness  in,  59 
Siderosis,  327 

Sinus,  frontal,  ethmoidal  and  sphenoidal, 
diseases  of,  205 

superior  longitudinal,  thrombosis  of, 
889 
Skin,  anaesthesia  of,  836 

bronzed,  74 

in  Addison's  disease,  748 

color  of,  69 

in  various  diseases,  70 

cyanosis  of,  72 


INDEX. 


933 


Skin,  eruptions  of,  factitious,  86 
in  internal  diseases,  77 

anatomical  characters  of, 

78 
associated   morbid   phe- 
nomena in,  79 
clinical  significance  of,77 
distribution  of,  79 
general  symptoms  in,  80 
table  of,  with  diseases  in 
which  they  may  occur, 
81 
traumatic,  86 
hemorrhage  into,  75 

with  fever,  76 
in  the  exanthemata,  76 
underneath,  181 
hyperemia  of,  69 
moisture  and  dryness  of,  89 
nodules  of,  100 
nutrition  of,  89 
pallor  of,  70 

parasitic  diseases  of,  in  carcinoma,  188 
yellow,  causes  of,  71 
"  Sleeping  sickness,"  filaria  in,  738 
Smallpox,  786 
Smell,  disturbances  of,  855 

sense  of,  disturbance  of,  195 
Solutions  of  aniline  dyes,  157 
Delafield's  hsematoxylin,  745 
Gram's,  158 
Loffier's,  158 

for  flagellar,  158 
Spansemia,  177 
Spasms,  839 

classification  of,  839 
co-ordinated,  840 
vasomotor,  841 
Speech,  centres  of,  845 
Spermatorrhoea,  701 
Spinal  column,  examination  of,  147 
cord,  anaemia  of,  871 

anterior  horns  of,  853 
antero-lateral  columns  of,  853 
compression  of,  872,  874 
degenerations  of,  876 
diseases  of,  bedsores  or  decubitus 

in,  185 
hemorrhage  into,  871,  876 
hypersemia  of.  871 
localization  of  lesions  in,  843,  852, 

854 
membranes  of,  hemorrhage  of,  871 
posterior  columns  of,  853 

in    pernicious     anaemia, 
742 
trophic  cells  of,  853 
tumors  of,  882 
unilateral  lesions  of,  853 
Spine,  pain  in,  46 
Spirilla,  154 

of  relapsing  fever,  in  blood,  735 
Spirillum  cholera?  Asiatic;?,  580,  809 
nostras,  582 
Obermeieri,  785 
Spirometry,  275 


Spleen,  acute  inflammation  of,  659 

amyloid,  660 

diseases  of,  657 

enlargement  of,  acute  and  chronic,  659 
distinguished  from  enlarged  left 
kidney,  659 
liver,  659 
in  leukaemia,  743 
in  simple  anaemia,  739 
in  young  children,  661 

floating,  658 

hydatid  tumor  of,  660 

hypertrophy  of,  in   chronic  malaria, 
660 

malignant  tumors  of,  660 

normal  dulness  of,  658 

palpation  of,  657 

percussion  of,  658 

puncture  of,  165 

syphilis  of,  660 
Spores,  staining  of,  158 
Sputum,  actinomyces  in,  293 

amoeba  dysenterise  or  coli  in,  286 

bacillus  of  influenza  in,  292 

bloody,  279 

of  capillary  bronchitis,  309 

chemistry  of,  293 

collection  of,  156 

connective  tissue  and  cartilage  in,  282 

crystals  in,  285 

currant  jelly,  280 

echinococcus  cysts  in,  286 

elastic  fibres  in,  281 

epithelium  in,  280 
alveolar,  281 

fibrinous  coagula  in,  282 

fixation  and  sectioning  of,  283 

of  foetid  bronchitis,  311 

laryngeal,  213 

leptothrix  in,  287 

method  of  collecting,  277 

micrococcus  lanceolatus  in,  292 

moulds  in,  286 

muco- purulent,  279 

mucous,  279 

physical  characteristics  of,  278 

in  pulmonary  tuberculosis,  336 

red  blood-corpuscles  in,  280 

purulent,  279 

sarcinae  pulmonalis  in,  287 

spirals  in,  283 

tubercle  bacillus  in,  288 

detection  of,  if  few  in  num- 
ber, 291 
importance  of,  291 
methods  of  staining,  288 

nummular,  279 

white  blood-corpuscles  in,  280 
Staining,  methods  of,  157 

of  syphilis-bacillus,  168 

of  tubercle-bacilli,  289 
Stains  (see  Solutions). 
Staphylococci,  152,  153 
Staphylococcus  pyogenes  aureus,  166,  167 

epidermidis  albus,  167 
Station,  61 


934 


INDEX. 


Sterilization,  in  bacteriology,  15-5 

intermittent,  155 
Stethoscopes,  261 
Stomach,  absorptive  power  of,  525 

artificial  distention  of,  by  gas  or  air, 

510,  514 
atony  of,  554 

succussion-sound  in,  515 
atrophy  of,  541 
auscultation  of,  514 
cancer  of,  541 

diagnosis  of,  543 

distinguished   from  chronic   gas- 
tritis, 544 
from  gastric  ulcer,  544 
from  hepatic  cancer,  642 
from  movable  kidney,  726 
examination   of  gastric    contents 

in,  543 
HC1  in,  527 
pain  in,  536 

supraclavicular  glands  in,  137 
vomiting  in,  531 
catarrh  of,  in   mitral    incompetency, 
434 
in  valvular  heart  disease,  556 
chronic,  541 
contents  of,  acetic  acid  in,  523 

albumoses  and  peptones  in,  523 

alcohol  in,  523 

anacidity  of,  554 

bile  and  intestinal  juice  in,  518 

blood  in,  518 

butyric  acid  in,  523 

carbohydrates  in,  524 

cause  of  increased  acidity  in,  526 

causes  of  diminished  acidity  in, 

526     • 
chemical  examination  of,  516,  520 
clinical  value  of  examination  of, 

526 
HC1  in,  tests  for,  520,  521 

quantitative  estimation  of,522 
significance  of,  527 
lactic  acid  in,  520,  522,  527 
methods  of  securing,  for  examina- 
tion, 515 
microscopical  examination  of,  519 
mucus  in,  517 
normal,  516 
rennin  in,  test  for,  524 
pepsin  in,  test  for,  524 
pus  in, 518 
syntonin  in,  524 
total  acidity  of,  520 
digestive  energy  of,  tests  for,  524 

power  of,  517 
dilatation  of,  510,  546,  513 
percussion-note  in,  514 
succussion-sound  in,  515 
diminution  in  size  of,  513 
diseases  of,  507 

alterations  of  appetite  in,  536 
cough  in,  537 

Ewald's  test-breakfast  in,  515 
flatulency  in,  533 


Stomach,  diseases  of,  dyspnoea  in,  537 
functional,  548 
hiccough  in,  537 
Leube-Riegel  test-dinner  in,  515 
morbid  processes  in  other  organs 

causing  symptoms  of,  509   • 
organs  functionally  related  to,  509 
in  other  diseases,  556 
pain  in,  534 

significance  of  time  of,  536 
and  tenderness  in,  512 
palpitation  in,  537 
pyrosis  or  waterbrash  in,  537 
regurgitation  of  gas  or  food  in,  537 
subjective  symptoms  of,  528 
central  and  reflex,  508 
functional,  508 
local,  507 
toxic,  509 
vertigo  in,  534 
excess  of  gas  in,  553 
"fibroid,"  511 
hemorrhage  from,  527 
causes  of,  528 

distinguished   from    haemoptysis, 
305,  528 
hyperacidity  and  hypersecretion  of,  in 

gastric  neuroses,  552 
juices  of,  test  for  activity  of,  525 
method  of  passing  tube  into,  515 
motor  power  of,  tests  for,  525 
neuroses  of,  Ewald's  table  of,  548  (see 

also  Dyspepsia), 
obstruction  of  pylorus  of,  symptoms 

in,  189 
palpation  of,  511 
percussion -area  of,  512,  514 
peristaltic  and  anti- peristaltic  waves 
of,  510 
unrest  of,  553 
physical  examination  of,  510 
position  of,  512 
relaxation  of  ends  of,  554 
rupture  of,  548 
succussion-sound  in,  514 
transillumination  of,  510 
tumors  of,  position  of,  511 
tympany  of,  distinguished  from  that  of 

colon,  514 
ulcer  of,  545 

cause    of   subdiaphragmatic    ab- 
scess, 506 
distinguished  from   chronic  gas- 
tritis, 544 
from  gastric  cancer,  544 
pain  in,  512,  536 
vomiting  in,  531 
use  and  misuse  of  bougie  in  examina- 
*  tion  of,  511 
Stomatitis,  461 
aphthous,  462 
catarrhal,  462 

of  foot-and-mouth  disease,  824 
gangrenous,  462 
materna,  462 
mercurial,  463 


INDEX. 


935 


Stomatitis,  parasitic  (or  thrush),  462 

ulcerative,  462 
Streptococci,  152 
Streptococcus  pyogenes,  167 
Succussion,  Hippocratic,  271,  349 

-sound,  in  dilated  stomach,  -547 
Sudamina,  86 
Suppuration,  cause  of,  166 
loss  of  appetite  in,  537 
symptoms  of,  183 
Swaying,  61 
Sweating,  in  fever,  110 

sickness,  90,  827 
Sphygmograph,  396 

Dudgeon's,  directions  for  using,  397 
technique  of  the,  397 
Symptoms  of  disease,  objective,  definition 
of,  17 
in  general  diagnosis,  49 
subjective,  definition  of,  17 
general,  33 
nature  of,  33 
value  of,  31 
Syncope,  118 

Synovitis,   distinguished   from   rheumatic 
fever,  754 
joint  of,  145 
Syphilis,  bacillus  of,  ]  68 
bony  nodules  in,  142 
brawny  induration  in,  100 
caries  of  cranial  bones  in,  124 
congenital,  eruptions  in,  88 
coryza  in,  203 
face  in,  121 

rigidity  of  chest  in,  237 
constitutional,  acquired,  828 

hereditary,  830 
eruptions  in,  87 
heredity  in,  28 

of  joints,  distinguished  from  rheuma- 
tism, 755 
laryngeal,  224 
lymphatic  glands  in,  137 
mucous  patches  in  mouth  in,  463 
nocturnal  pains  in,  40 
subcutaneous  nodes  in,  101 
tenderness  of  sternum  in,  142 
tertiary  ulcers  of,  88 
of  tongue,  467 

ulceration  of  pharynx  in,  478 
Syphilodermata,  87 
Syringomyelia,  882 


TABES    dorsalis,    876    (see    Locomotor 
Ataxia), 
mesenterica,  507,  620 
Tachycardia,  375,  395 
Taenia?,  576 

symptoms  of,  559 
Teeth,  carious,  cause  of  headache  or  neu- 
ralgia, 460 
in  congenital  syphilis,  460 
dates  of  eruption  of,  461 
effect  of  stomatitis  on,  460 
in  gout,  460 


Teeth  in  hereditary  syphilis,  830 
Temperament,  general  discussion  of,  55 
Temperature  (.see  also  Fever). 

collapse,  104 

determination  of,  101 

febrile,  104 

in  gastric  cancer,  542 

high,  dangers  in,  104 

hyperpyretic,  104 

of  mouth,  103 

pathological  variations  of,  103 

physiological  variations  of,  103 

rectal  and  axillary,  102 

sense  of,  836 

subnormal,  110,  114 

sudden  fall  of,  114 
Test-papers,  benzo-purpurin,  520 

Congo-red,  520 

phloroglucin  vanillin,  521 
tropaeolin,  521 
Tetanus.  896 

bacillus  of,  170 
Tetany,  897 

in  gastric  dilatation,  547 

in  rhachitis,  761 
Thalamus,  optic,  lesions  of,  849,  888 
Thermometers,  clinical,  101 
Thirst,  in  gastric  disease,  529 
Thomsen's  disease,  141,  881 
Thorax  (see  Chest  i. 

reflex  pain  in,  45 
Thrombosis,  in  arterial  sclerosis,  445 

causes  of,  179 

cerebral,  890 

pulmonary,  319 

symptoms  of,  179 
Thrush,  458,  459,  462 
Thyroid,  abscess  of,  129 

atrophy  of,  129 

enlargements  of,  129 

excision  of,  tetany  in,  897 
Tic  convulsif,  861 

douloureux,  837,  861 
Tinea  versicolor,  74 
Tinea?,  88 
Tongue,  464 

in  angina  Ludovici,  475 

atrophy  of,  469 

black,  465 

in  catarrhal  stomatitis,  462 

classification  of,  472 

coating  on,  469,  470 

in  cyanosis,  72,  471 

cysts  of,  469 

discoloration  s  of,  464 

in  disorders  of  gastro-intestinal  tract, 
464 

dry,  brown,  471 

eflects  of  food  on,  473 

of  general  disease  on,  469,  474 

eruptions  on,  466 

furred  or  shaggy,  471 

furrows  of,  466 

hypertrophy  of,  469 

indentations    and    excoriations  of, 
466 


936 


INDEX. 


Tougue,    inflammation    of,    465    (see    also 
Glossitis ). 
chronic  superficial,  466,  469 

moisture  of,  472 

movements  of,  474 

nodules  in,  469 

pain  in  cancer  of,  42 

patches  and  plaques  on,  468 

pigmentations  of,  464 

plaster,  470 

in  prognosis  and  treatment,  474 

red  dry,  471 

in  relation  to  diseases  of  alimentary 
canal,  473 

ringworm  of,  469 

stippled  or  dotted,  470 

strawberry-,  470 

syphilitic  lesions  of.  467 

ulcers  of,  466,  467 
Tonsillitis,  480 

chronic,  483 

diagnosis  of,  482 

follicular,  albuminuria  in,  48 
bad  drainage  cause  of,  481 
distinguished    from    diphtheria, 

482,  805 
foetor  of  breath  in,  480 
non-contagiousness  of,  481 
symptoms  of,  481 

herpetic,  480,  482 

in  scarlatina,  796 

suppurative,  482 
Tonsils,  affections  of,  477 

diseases    of,    in    rheumatic     states, 
476 

exudations  on,  479 

foreign  bodies  in,  483 

leptothrix- of,  479 
Torticollis,  756,  865 

facial  asymmetry  in,  122 
Toxaemia,  151 

fatigue  in,  34 

pain  in,  41 
Toxalbumins,  153 
Trachea,  obstruction  of,  dyspnoea  in,  294 

causes  of,  295 
Tracheal  tugging,  128 
Transudations,  173 
Tremor,  839 
Triangle,  cardio-hepatic,  364 

Simon's,  786 
Trichina  spiralis,  in  faeces,  578 
Trichinosis,  827 

face  in,  122 

oedema  in,  95 
Trichomonas  intestinalis,  576 

in  urine,  703 
Tricuspid  incompetency,  436 
venous  pulse  in,  405 

stenosis,  437 
Trismus,  861 
Trophic  disturbances,  841 
Tube,  stomach-,  515 
Tubercle-bacilli,  stain  for,  290 
Tuberculosis,  831 

acute,  cyanosis  in,  73 


Tuberculosis,    acute,    distinguished    from 
typhoid,  781 
miliary,  329,  832 

distinguished  from  bronchi- 
tis, 307 
of  apices,  306 
bacillus  of,  in  faeces,  582 
in  pus,  168 
in  sputum,  288 
chronic,  330 

cough  in,  cause  of,  300,  302 
in  diabetes,  764 
early  seats  of,  331 
modes  of  origin  of,  331 
pain  in  pleurisy  of,  305 
pulmonarv,  diagnostic  features  of, 
333 
diseases  from    which   to   be 
distinguished,  337 
which  it  may  follow,  331, 
337 
fever  in,  333 

physical  signs  of,  333,  336 
sputum  in,  336 
confounded  with  malaria,  814 
diathesis  of,  55 
gingival  line  in,  459 
glandular,  distinguished  from  Hodg- 

kin's  disease,  747 
laryngeal,   subcutaneous    emphvsema 

in,  98 
of  larynx,  222 
of  mesenteric  glands,  507 
of  occipito-atlantal  articulation,  124 
pulmonary,  acute,  327 

confounded  with  aortic  aneurism, 

447,  453 
definition  of,  327 
distinguished  from  bronchiectasis, 

313 
fibroid,  326 

gastric  symptoms  in,  556 
hemorrhage  in,  303 
importance   of  early  recognition 
of,  332 
of  tubercle-bacilli  in  sputum 
of,  291 
pericardial  adhesions  in,  421 
vomiting  in,  532 
synovitis  in,  145 
of  tongue,  468 

ulceration  of  pharynx  in,  479 
weight  in,  64 
Tumors  of  abdomen,  498 
"phantom,"  498,  638 
nasal,  204 

and  new  growths,  187 
Tympanites,  hysterical,  901 
Typhlitis,  502,' 607 
Typhoid  croupous  pneumonia,  324 
fever,  770  (see  also  Fever), 
state,  107 

described,  58 
tongue  in,  471 
in  uraemia,  709 
Typhus  fever,  781 


INDEX. 


937 


ULCER,  malignant,  89 
of  nose,  neuro-paralytic,  199 

post-febrile,  199 
rodent,  89 
tertiary,  88 
Uraemia,  asthma  in,  297 

cardio-vascular  symptoms  in,  711 
distinguished  from  typhoid,  781 

from  typhus,  783 
dropsy  in,  712 
dyspnoea  in,  710 

gastro-intestinal  symptoms  in,  710 
hemorrhage  in,  712 
nervous  symptoms  in,  709 
ophthalmoscopic  changes  in,  7-12 
temperature  in,  709 
Urea,  estimation  of,  680 
Ureters,  catheterization  of,  674 
Urine,  acetone  in,  691 

albumin  in,  causes  of,  684 

quantitative  estimation  of,  684 

tests  for,  681-684 
albumose  in,  687 

bile-pigments  and  bile-acids  in,  691 
blood  in,  695 

causes  of,  686 
bloody,  in  cardiac  disease,  413 
casts  in,  method  of  examining  for,  696 

varieties  of,  698 
chemical  examination  of,  679 
chlorides  in,  estimation  of,  681 
cholesterin  in,  707 
color  of,  normal  and  abnormal,  675 
cylindroids  in,  700 
cystin  in,  707 
diacetic  acid  in,  692 
entozoa  in,  702 
epithelium  in,  701 
fat  and  chyle  in,  701 
haemoglobin  in,  687 
indican  in,  690 

in  intestinal  obstruction,  600 
in  lithaemia,  624 
leucin  and  tyrosin  in,  707 
melanin  in,  709 
micro  organisms  in,  702 
microscopical  examination  of,  692 

centrifugal  machine  in,  692 
mucin  in,  686 
odor  of,  679 
oxalate  of  lime  in,  706 
peptone  in,  685 
phosphates  in,  705 
pus  in,  691,  695 
reaction  of,  678 
sediments  in,  678 
solids  in,  specific  gravity  as  index  of, 

678 
specific  gravity  of,  677 
spermatozoa  in,  700 
sugar  in,  tests  for,  687-689 

precautions  in  applying  tests  for, 
688 

quantitative  estimation  of,  689 
suppression  of.  causes  of,  676 

in  malaria,  814 


Urine,  tumor-elements  in,  703 

urates  in,  704 

urea  in,  679 

uric  acid  in,  703 

volume  of,  675 

in  disease,  676 
Urticaria,  84 

Uterus,  disease  of,  pigmentation  in,  74 
Uvula,  affections  of,  478 


yARICELLA,  789 
y      distinguished  from  variola,  788 
Variola,  786 
Varioloid,  787 
Valleix's  tender  points,  306 
Valve,  ileo-csecal,  cancer  of,  503 
Vasomotor  apparatus,  191 
Veins,  general  increase  in  fulness  of,  403 

hum  heard  over,  406 

local  increase  in  fulness  of,  403 

portal,   obstruction  of,  symptoms  in, 
626 

pulsation  of,  404 

in  tricuspid  regurgitation,  437 

thrombosis  of,  406 
Venous  hum,  406 
Vertebrae,  cervical,  disease  of,  486 

diseases  of,  pain  in,  46,  563 
Vertebral  canal,  aspiration  of,  165 
Vertigo,  aural,  863 

in  gastric  affections,  534 

paralyzing,  864 
Volvulus,  595,  601 
Vomiting,  cerebral,  533 

chronic,  in  rhachitis,  761 

crises  of,  533 

distinguished  from  regurgitation,  517 

in  gastric  disease,  529,  531 

in   incipient   pulmonary  tuberculosis, 
336 

morning,  in  uraemia,  710 

in  onset  of  acute  diseases,  530 

physiology  of  529 

pseudo-hysterical,  553 

reflex,  532 

significance  of,  530 

in  toxaemias,  533 

ursemic,  533 
Von  Graefe's  sign,  126 


WASTING,  rapid,  in  aortic  aneurism, 
447 
Weight,  in  children,  65 

diseases  causing  continuous  loss  of,  65 

false,  increase  of,  64 

Hutchinson's  table  of,  64 

in  relation  to  height,  63 
Weil's  disease,  633 
Whooping-cough,  217,  798 

cough  in,  302 

distinguished  from  bronchitis,  308 

mediastinal  inflammation  in,  453 

sublingual  ulcer  in,  463 
Williams'  tracheal  tone,  273 


938 


INDEX. 


Wintrich's  sign  of  cavity,  273 

in  pneumothorax,  349 
Word-blindness,  847 

-deafness,  846 
Worms,  intestinal,  symptoms  of,  559 

round,  577 

tape-,  576 

thread-,  578 
Wrist-drop,  131 


Writer's  cramp,  898 
Wry-neck,  865 

XANTHELASMA,  125,  464,  629 
Xerastoma,  455 

7IEHL-NEELSEN  stain  for  tubercle- 
L     bacilli,  290 
Z06glce.se,  152 


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KOCH'S   REMEDY  IN  RELATION  ESPECIALLY    TO    THROAT 

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BRUCE    (J.    MITCHELL).     MATERIA    MEDIC  A    AND    THERAPEUTICS. 

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BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY,  THERA- 
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Action  and  the  Therapeutical  Uses  of  Drugs.     In  one  octavo  volume. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth  American 
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illustrations.     Cloth,  $6.50 ;  leather,  $7.50.. 

BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  See  Taylor  on  Venereal  Diseases, 
page  15.     Just  ready. 

BURNETT   (CHARLES  H.).     THE  EAR:  ITS  ANATOMY,  PHYSIOLOGY 

AND  DISEASES.     A  Practical  Treatise  for  the  Use  of  Students  and  Practitioners. 

Second  edition.     In  one  8vo.  volume  of  580  pages,  with  107  illustrations.     Cloth,  $4 ; 

leather,  $5. 
BUTLIN    (HENRY   T.).     DISEASES   OF   THE   TONGUE.    In  one  pocket-size 

12mo.  volume  of  456  pages,  with  8  colored  plates  and  3  engravings.     Limp  cloth,  $3.50. 

See  Series  of  Clinical  Manuals,  page  13. 

CARPENTER  (W.  B.).  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC 
LIQUORS  IN  HEALTH  AND  DISEASE.  New  edition,  with  a  Preface  by  D.  F. 
Condie,  M.D.     One  12mo.  volume  of  178  pages.     Cloth,  60  cents. 

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one  plate.     Cloth,  $2.25.     See  Series  of  Clinical  Manuals,  page  13. 

CASPARI  (CHARLES,  JR.).  A  TREATISE  ON  PHARMACY.  For  Students 
and  Pharmacists.  In  one  handsome  octavo  volume  of  680  pages,  with  288  illustrations. 
Just  ready.     Cloth,  $4.50. 

CHAMBERS  (T.  K.).    A  MANUAL  OF  DIET  IN  HEALTH  AND  DISEASE. 

In  one  handsome  8vo.  volume  of  302  pages.     Cloth,  $2.75. 

CHAPMAN  (HENRY  C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    In 

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CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIOLOGICAL 
AND  PATHOLOGICAL  CHEMISTRY.  In  one  handsome  octavo  volume  of  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  (W.  WATSON).  THE  TREATMENT  OF  WOUNDS,  ULCERS 
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CHURCHILL  (FLEETWOOD).  ESSAYS  ON  THE  PUERPERAL  FEVER. 
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CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).  THE  DISSECTOR'S  MANUAL. 
In  one  12mo.  volume  of  396  pages,  with  49  engravings.  Cloth,  $1.50.  See  Students'  Series 
of  Manuals,  page  14. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF  THE 
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CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  13. 

CLOUSTON  (THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL  DIS- 
EASES. With  an  Abstract  of  Laws  of  U.  S.  on  Custody  of  the  Insane,  by  C.  F.  Fol- 
som,  M.D.  In  one  handsome  octavo  volume  of  541  pages,  illustrated  with  engravings 
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octavo  volume  of  108  pages.     Cloth,  $1.50. 

CLOWES    (FRANK).  AN   ELEMENTARY   TREATISE    ON  PRACTICAL 

CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALYSIS.    From  the 

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ings.    Cloth,  $2.50. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  volume  of  829 
pages,  with  339  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND  PATH- 
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CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DISEASES 
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CORNIL  (V.\  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
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CULBRETH  (DAVID  M.  R.\    MATERIA  MEDIC  A  AND  PHARMACOLOGY. 

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CULVER  (E.  M.)  AND  HAYDEN  (J.  R.).  MANUAL  OF  VENEREAL  DIS- 
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DALTON  (JOHN  C).  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Seventh 
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of  722  pages,  with  252  engravings.     Cloth,  $5 ;  leather,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In  one  hand- 
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DAVIS  (F.H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second  edition.  In 
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DE  SCHWEINITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS ;  THEIR 
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titioners of  Medicine.  In  one  handsome  octavo  volume  of  734  pages,  with  376  engrav- 
ings.    Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
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Boyd,  F.B.C.S.  In  one  large  octavo  volume  of  965  pages,  with  373  engravings.  Cloth,  $4 ; 
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DUANE  (ALEXANDER).  THE  STUDENT'S  DICTIONAR  Y  OF  MEDICINE 
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175  pages.     Cloth,  $1.50. 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE.  Con- 
taining a  full  Explanation  of  the  Various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacy,  Pharmacology,  Therapeutics,  Medicine,  Hygiene,  Dietetics, 
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Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc.  By  Robley  Dungli- 
son,  M.D.,  LL.D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia.  Edited  by  Richard  J.  Dtjnglison,  A.M.,  M.D.  Twenty-first 
edition,  thoroughly  revised  and  greatly  enlarged  and  improved,  with  the  Pronunciation, 
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EDES  (ROBERT  T.\  TEXT-BOOK  OF  THERAPEUTICS  AND  MATERIA 
MEDIC  A.     In  one  8vo.  volume  of  544  pages.     Cloth,  $3.50;  leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for  Students  and 
Practitioners.  In  one  handsome  8vo.  volume  of  576  pages,  with  148  engravings. 
Cloth,  $3 ;  leather,  $4. 

ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY.  Being  a 
Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection.  From  the  eighth  and  revised 
English  edition.  In  one  octavo  volume  of  716  pages,  with  249  engravings.  Cloth,  $4.25 ; 
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and  revised.  In  one  large  8vo.  volume  of  880  pages,  with  150  original  engravings. 
Cloth,  §5  ;  leather,  §6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SURGERY.  A  new- 
American  from  the  eighth  enlarged  and  revised  London  edition.  In  two  large  octavo 
volumes  containing  2316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  American  Text-books 
of  Dentistry,  page  2. 

FARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS.  Fourth 
American  from  fourth  English  edition,  revised  by  Frank  Woodbury,  M.D.  In  one 
12mo.  volume  of  581  pages.     Cloth,  §2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fourth 
edition.  In  one  octavo  volume  of  391  pages,  with  73  engravings  and  21  colored  plates. 
Cloth,  §3.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  New  (7th)  edition,  thoroughly  revised  by  Frederick  P.  Henry, 
M.D.     In  one  large  8vo.  volume  of  1143  pages,  with  engravings.     Cloth,  §5 ;  leather,  $6. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION;  of  the  Physi- 


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edition,  revised  by  James  C.  Wilson,  M.D.  In  one  handsome  12mo.  volume  of  274 
pages,  with  12  engravings. 

A   PRACTICAL    TREATISE   ON  THE  DIAGNOSIS  AND    TREAT- 


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octavo  volume  of  550  pages.     Cloth,  §4. 

A   PRACTICAL   TREATISE  ON  THE  PHYSICAL  EXPLORATION 


OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING 
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ume of  591  pages.     Cloth,  $4.50. 

MEDICAL  ESS  A  YS.    In  one  12mo.  volume  of  210  pages.     Cloth,  $1.38. 

ON  PHTHISIS :  ITS  MORBID  ANA  TOMY,  ETIOL  OGY,  ETC.     A  Series 


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FOLSOM  (0.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S.  ON  CUSTODY 
OF  THE  INSANE.     In  one  8vo.  volume  of  108  pages.     Cloth,  $1.50. 

FORMULARY,  THE  NATIONAL.  See  SHIM,  Maisch  &  Caspar? s  National  Dispensa- 
tory, page  14. 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  (6th)  and 
revised  American  from  the  sixth  English  edition.  In  one  large  octavo  volume  of  923 
pages,  with  257  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND-BOOK  OF 
TREATMENT.  Third  edition.  In  one  handsome  octavo  volume  of  664  pages. 
Cloth,  $3.75 ;  leather,  $4.75. 

FOWNES  i GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY  (IN- 
ORGANIC AND  ORGANIC).  Twelfth  edition.  Embodying  Watts'  Physical  and 
Inorganic  Chemistry.  In  one  royal  12mo.  volume  of  1061  pages,  with  168  engravings,  and 
1  colored  plate.     Cloth,  $2.75  ;  leather,  $3.25. 

FRANKLAND  iE.)  AND  JAPP  (F.R.I.    INORGANIC  CHEMISTRY.    In  one 

handsome  octavo  volume  of  677  pages,  with  51  engravings  and  2  plates.     Cloth,  $3.75 ; 
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FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  ORGANS  IN  THE 
MALE.  In  one  very  handsome  octavo  volume  of  238  pages,  with  25  engravings  and 
8  full-page  plates.     Cloth,  $2.     Just  ready. 

FULLER  (HENRY).  ON  DISEASES  OF  THE  L  UNGS  AND  AIR-PASSAGES. 
Their  Pathology,  Physical  Diagnosis,  Symptoms  and  Treatment.  From  second  English 
edition.     In  one  8vo.  volume  of  475  pages.     Cloth,  $3.50. 


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GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  AMultumin 
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GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID  HIS- 
TOLOGY. In  one  very  handsome  octavo  volume  of  314  pages,  with  60  illustrations, 
mostly  photographic.     Cloth,  $2.75. 

GIBNEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practitioners  and 
Students.     In  one  8vo.  volume  profusely  illustrated.     Preparing. 

GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo.  volume  of  589 
pages.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  14. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL.  A  new 
American  edition,  thoroughly  revised.  In  one  imperial  octavo  volume  of  1250  pages, 
with  772  large  and  elaborate  engravings.  Price  with  illustrations  in  colors,  cloth,  $7 ; 
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GRAY  (LANDON  CARTER).  A  TREATISE  ON  NERVOUS  AND  MENTAL 
DISEASES.  For  Students  and  Practitioners  of  Medicine.  New  (2d)  edition.  In  one 
handsome  octavo  volume  of  728  pages,  with  172  engravings  and  3  colored  plates.  Cloth, 
$4.75;  leather,  $5  75.     Just  ready. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND  MOR- 
BID ANATOMY.  New  (7th)  American  from  the  eighth  London  edition.  In  one 
handsome  octavo  volume  of  595  pages,  with  224  engravings  and  a  colored  plate.  Cloth, 
$2.75. 

GREENE  (WILLIAM  H.).    A  MANUAL  OF  MEDICAL  CHEMISTRY.    For 

the  Use  of  Students.     Based  upon  Bowman's  Medical  Chemistry.     In  one  12mo.  volume 
of  310  pages,  with  74  illustrations.     Cloth,  $1. 75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  thoroughly 
revised  and  edited  by  Samuel  W.  Gross,  M.  D.  ~\  In  one  octavo  volume  of  574  pages, 
with  170  illustrations.     Cloth,  $4.50. 

HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN,  comprising 
those  of  the  Stomach,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  Second  Amer- 
ican from  the  third  English  edition.  In  one  octavo  volume  of  554  pages,  with  11  engrav- 
ings.    Cloth,  $3.50. 

HAMILTON  ( ALLAN  McL ANE ) .  NER  VO  US  DISEASES,  THEIR  DESCRIP- 
TION AND  TREATMENT.  Second  and  revised  edition.  In  one  octavo  volume  of 
598  pages,  with  72  engravings.     Cloth,  $4. 

HAMILTON  FRANK  H.).  A  PRACTICAL  TREATISE  ON  FRACTURES 
AND  DISLOCATIONS.  Eighth  edition,  revised  and  edited  by  Stephen  Smith, 
A.M.,  M.D.  In  one  handsome  octavo  volume  of  832  pages,  with  507  engravings. 
Cloth,  $5.50;  leather,  $6.50. 

HARD  A  WAY  iW.A.).  MANUAL  OF.  SKIN  DISEASES.  In  one  12mo.  volume 
of  440  pages.     Cloth,  $3. 

HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL  THERA- 
PEUTICS, with  Special  Reference  to  the  Application  of  Remedial  Measures  to  Disease 
and  their  Employment  upon  a  Rational  Basis.  With  articles  on  various  subjects  by  well- 
known  specialists.  New  (5th)  and  revised  edition.  In  one  octavo  volume  of  740  pages. 
Cloth,  $3.75;  leather,  $4.75.     Just  ready. 

PRACTICAL  DIAGNOSIS.    The  Use  of  Symptoms  in  the  Diagnosis  of  Disease. 

In  one  octavo  volume  of  566  pages,  with  191  engravings,  and  13  full  page  plates  in  colors 
and  monochrome.     Cloth,  $4.75.     Just  ready. 

HARE  (HOBART  AMORY),  Editor.  A  SYSTEM  OF  PRACTICAL  THERA- 
PEUTICS. By  American  and  Foreign  Authors.  In  a  series  of  contributions  by  78 
eminent  Physicians.  Three  large  octavo  volumes  comprising  3544  pages,  with  434 
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HARTSHORNE  (HENRY).  ESSENTIALS  OF  TEE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo.  volume,  669  pages, 
with  144  engravings.     Cloth,  $2.75;  half  bound,  $3. 

A   HANDBOOK  OF  ANATOMY  AND   PHYSIOLOGY.    In  one  12mo. 

volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising  Manuals 


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HAYDEN  (JAMES  R.).     A  MANUAL  OF  VENEREAL  DISEASES.     In  one 

12mo.  volume  of  263  pages,  with  47  engravings.     Cloth,  $1.50.     Just  ready. 

HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND  NATURAL 
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pheric Pressure,  Climates  and  Mineral  Waters.  Edited  by  Prof.  H.  A.  Hare,  M.D. 
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HERMAN    (G.    ERNEST).     FIRST  LINES  IN  MIDWIFERY.     In  one  12mo. 

volume  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See  Students'  Series  of  Manuals, 
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HERMANN  (L.).  EXPERIMENTAL  PHARMACOLOGY.  A  Handbook  of  the 
Methods  for  Determining  the  Physiological  Actions  of  Drugs.  Translated  by  Robert 
Meade  Smith,  M.D.     In  one  12mo.  vol.  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 

HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In  one  handsome 
12mo.  volume  of  429  pages,  with  80  engravings  and  2  colored  plates.  Cloth,  $2.50. 
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HILL  (BERKELEY).    SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS. 

In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  Second  edition. 
In  one  royal  12mo.  volume  of  353  pages,  with  two  plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.).  HUMAN  MONSTROS- 
ITIES. Magnificent  folio,  containing  220  pages  of  text  and  illustrated  with  123  engrav- 
ings and  39  large  photographic  plates  from  nature.  In  four  parts,  price  each,  $5.  Limited 
edition.     For  sale  by  subscription  only. 

HOBLYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS  USED  IN 
MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one  12mo.  volume  of 
520  doubled-columned  pages.     Cloth,  $1.50;  leather,  $2. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN,  INCLUDING 
DISPLACEMENTS  OF  THE  UTERUS.  Second  and  revised  edition.  In  one 
8vo.  volume  of  519  pages,  with  illustrations.     Cloth,  $4.50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.).  A  MANUAL 
OF  CHEMICAL  ANAL  YSIS,  as  Applied  to  the  Examination  of  Medicinal  Chemicals 
and  their  Preparations.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one 
handsome  octavo  volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLDEN  (LUTHER).  LANDMARKS,  MEDICAL  AND  SURGICAL.  From 
the  third  English  edition.  With  additions  by  W.  W.  Keen,  M.D.  In  one  royal  12mo. 
volume  of  148  pages.     Cloth,  $1. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Principles  and 
Practice.  A  new  American  from  the  fifth  English  edition.  Edited  by  T.  Pickering 
Pick,  F.R.C.S.  In  one  handsome  octavo  volume  of  1008  pages,  with  428  engravings. 
Cloth,  $6 ;  leather,  $7 

A  SYSTEM  OF  SURGERY.     With  notes  and  additions  by  various  American 

authors.  Edited  by  John  H.  Packard,  M.D.  In  three  very  handsome  8vo.  volumes 
containing  3137  double-columned  pages,  with  979  engravings  and  13  lithographic  plates. 
Per  volume,  cloth,  $6;  leather,  $7  ;  half  Russia,  $7.50.     For  sale  by  subscription  only. 

HORNER  ("WILLIAM  E.).  SPECIAL  ANATOMY  AND  HISTOLOGY.  Eighth 
edition,  revised  and  modified.  In  two  large  8vo.  volumes  of  1007  pages,  containing  320 
engravings.     Cloth,  $6. 

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HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one  octavo 
volume  of  308  pages.     Cloth,  $2.50. 

HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo.  volume  of 
542  pages,  with  8  chromo-lithographic  plates.  Cloth,  $2.25.  See  Series  of  Clinical  Man- 
uals, page  13. 

HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DISEASES  OF 
THE  SKIN.  Third  edition,  thoroughly  revised.  In  one  octavo  volume  of  802  pages, 
with  108  engravings  and  9  colored  plates.     Cloth,  $5 ;  leather,  $6. 

JACKSON  (GEORGE  THOMASK  THE  READY-REFERENCE  HANDBOOK 
OF  DISEASES  OF  THE  SKIN.  New  (2d)  edition.  In  one  12mo.  volume  of  589 
pages,  with  69  engravings,  and  one  colored  plate.     Cloth,  $2. 75.     Just  ready. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third  edition.  In  one 
octavo  volume  of  656  pages,  with  1  engraving  and  9  double-page  chromo-lithographic 
plates.     Cloth,  $6. 

JONES  (C.  HANDFIELD).  CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NER  VO  US  DISORDERS.  Second  American  edition.  In  one  octavo  volume  of  340 
pages.     Cloth,  $3.25. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PRACTICE.  Second  edition.  In  one  octavo  volume  of  549  pages,  with  201  engrav- 
ings, 17  chromo-lithographic  plates,  test-types  of  Jaeger  and  Snellen,  and  Holmgren's 
Color-Blindness  Test.     Cloth,  $5.50;  leather,  $6.50. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  American  Text-books  oj 
Dentistry,  page  2. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Sixth  edition.  In  one  12mo. 
volume  of  532  pages,  with  221  illustrations.     Cloth,  $2.50. 

KLEIN  (E.).     ELEMENTS  OF  HISTOLOGY.     Fourth  edition.     In  one  pocket-size 

12mo.  volume  of  376  pages,  with  194  engravings.     Cloth,  $1.75.     See  Student^  Series  of 
Manuals,  page  14. 

LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LABOR.  In  one  handsome 
12mo.  volume  of  329  pages,  with  28  illustrations.     Cloth,  $1.75. 

LA    ROCHE     (R.).     YELLOW   FEVER.     In    two    8vo.    volumes  of    1468  pages. 

Cloth,  $7. 

PNEUMONIA.     In  one  8vo.  volume  of  490  pages.     Cloth,  $3. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY-BOOK  OF 
OPHTHALMIC  SURGERY.  Second  edition.  In  one  octavo  volume  of  227  pages, 
with  66  engravings.     Cloth,  $2.75. 

LAWSON  (GEORGE).  INJURIES  OF  THE  EYE,  ORBIT  AND  EYELIDS. 
From  the  last  English  edition.  In  one  handsome  octavo  volume  of  404  pages,  with  92 
engravings.     Cloth,  $3.50. 

LEA  (HENRY  C).  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF 
SPAIN;  CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI ; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA ;  BRI- 
ANDA  DE  BARDAXI.    In  one  12mo.  volume  of  522  pages.     Cloth,  $2.50. 

A  HISTORY  OF  AURICULAR  CONFESSION  AND  INDULGENCES 


IN  THE  LATIN  CHURCH.     In  three  octavo  volumes  of  about  500  pages  each. 
Per  volume,  cloth,  $3.      Complete  work  just  ready. 

FORMULARY  OF  THE  PAPAL  PENITENTIARY.     In  one  octavo  vol- 


ume of  221  pages,  with  frontispiece.     Cloth,  $2.50. 

SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER  OF  LAT 


THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND  TORTURE.  Fourth 
edition,  thoroughly  revised.  In  one  handsome  royal  12mo.  volume  of  629  pages. 
Cloth,  $2.75.  

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LEA  (HENRY  C).  STUDIES  IN  CHURCH  HISTORY.  The  Eise  of  the  Tem- 
poral Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one  handsome 
12mo.  volume  of  605  pages.     Cloth,  $2.50. 

AN  HISTORIC A L  SKETCH  OF  SACERDOTAL  CELIBACY  IN  THE 


CHRISTIAN  CHURCH.     Second  edition.     In  one  handsome  octavo  volume  of 
pages.     Cloth,  $4.50. 

LEE  (HENRY)   ON  SYPHILIS.     In  one  8vo.  volume  of  246  pages.     Cloth,  $2.25. 

LEHMANN  (C.  G.).  A  MANUAL  OF  CHEMICAL  PHYSIOLOGY.  In  one 
8vo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 

LEISHMAN  (WILLIAM).  A  SYSTEM  OF  MIDWIFERY.  Including  the  Dis- 
eases of  Pregnancy  and  the  Puerperal  State.     Fourth  edition.     In  one  octavo  volume. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN),  Editors.  A  SYS- 
TEM OF  MEDICINE.  In  Contributions  by  Various  American  Authors.  In  four 
very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  black  and 
colors.     Volume  L,  in  press  for  early  issue. 

LUDLOW  (J.  L.).  A  MANUAL  OF  EXAMINATIONS  UPON  ANATOMY, 
PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE,  OBSTETRICS, 
MATERIA  MEDICA,  CHEMISTRY,  PHARMACY  AND  THERAPEUTICS. 
To  which  is  added  a  Medical  Formulary.  Third  edition.  In  one  royal  12mo.  volume 
of  816  pages,  with  370  engravings.     Cloth,  $3.25 ;  leather,  $3.75. 

LUFF  (ARTHUR  P.).  MANUAL  OF  CHEMISTRY,  for  the  use  of  Students  of 
Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  engravings.  Cloth,  $2.  See 
Students'  Series  of  Manuals,  page  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one  very  hand- 
some  octavo  volume  of  925  pages  with  170  engravings.     Cloth,  $4.75;  leather,  $5.75. 

LYONS  (ROBERT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo  volume  of  362 
pages.     Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  THE  DISEASES  OF  THE  NOSE  AND 
THROAT.  In  one  handsome  octavo  volume  of  about  600  pages,  richly  illustrated. 
Preparing, 

MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA  MEDICA. 
New  (6th)  edition,  thoroughly  revised  by  H.  C.  C  Maisch,  Ph.G.,  Ph.D.  In  one  very 
handsome  12mo.  volume  of  509  pages,  with  286  engravings.     Cloth,  $3. 

MANUALS.  See  Students'  Quiz  Series,  page  14,  Students'  Series  of  Manuals,  page  14,  and 
Series  of  Clinical  Manuals,  page  13. 

MARSH  (HOWARD  \  DISEASES  OF  THE  JOINTS.  In  one  12mo.  volume  of 
468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2.  See  Series  of  Clinical 
Manuals,  page  13. 

MAY   (C.  H.)    MANUAL  OF  THE  DISEASES  OF  WOMEN.     For  the  use  of 

Students  and  Practitioners.     Second  edition,  revised  by  L.  S.  Rait,  M.D.     In  one  12mo. 
volume  of  360  pages,  with  31  engravings.     Cloth,  $1.75. 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERVES  AND  THEIR'  TREATMENT.  In  one  handsome  12mo.  volume  of  239 
pages,  with  12  illustrations.     Cloth  $1.75.     Just  ready. 

MORRIS    (HENRY).    SURGICAL    DISEASES  OF    THE   KIDNEY.     In  one 

12mo.  volume  of  554  pages,  with  40  engravings  and  6  colored  plates.     Cloth,  $2.25.     See 
Series  of  Clinical  Manuals,  page  13. 


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LEA     BROTHERS    &     CO.'  S    PUBLICATIONS.  11 

MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  In  one  square  8vo.  volume 
of  572  pages,  with  19  chrorao-lithographic  figures  and  17  engravings.     Cloth,  §3.50. 

MULLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.  In  one 
large  8vo.  volume  of  623  pages,  with  538  engravings.     Cloth,  $4.50. 

MUSSER  (JOHN  H.).    A   PRACTICAL   TREATISE   ON  MEDICAL  DIAG- 
NOSIS, for  Students  and  Physicians.     New  (2d)  edition.     In  one  octavo  volume  of 
about  925    pages,  illustrated   with  177   engravings  and  11  colored  plates.     Cloth,  $5 
leather,  §6.     Just  ready. 

NATIONAL  DISPENSATORY.     See  Stille,  Maisch  &  Caspari,  page  14. 

NATIONAL  FORMULARY.  See  Stille,  Maisch  &  Caspari's  National  Dispensatory, 
page  14. 

NATIONAL  MEDICAL  DICTIONARY.    See  Billings,  page  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Fourth  American  from  fifth 
English  edition.  In  one  12mo.  volume  of  504  pages,  with  164  engravings,  test-types  and 
formulae  and  color-blindness  test.     Cloth,  $2. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF  OPHTHAL- 
MOLOGY. In  one  octavo  volume  of  641  pages,  with  357  engravings  and  5  colored 
plates.     Cloth,  §5 ;  leather,  $6. 

OWEN  (EDMUND).    SURGICAL  DISEASES  OF  CHILDREN.     In  one  12mo. 

volume  of  525  pages,  with  85  engravings  and  4  colored  plates.     Cloth,  $2.     See  Series  oj 
Clinical  Manuals,  page  13. 

PARK  (ROSWELL),  Editor.  A  TREATISE  ON  SURGERY,  by  American  Authors. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  In  two  magnificent  octavo 
volumes,  containing  1600  pages,  with  about  850  engravings,  and  about  40  full  page  plates 
in  colors  and  monochrome.  Complete  work  just  ready.  Price  per  volume,  cloth,  $4. 50 ; 
leather,  $5.50.     Net. 

PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS  CLINICAL 
HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREATMENT.  In  one  octavo 
volume  of  272  pages.     Cloth,  $2.50. 

PARVIN   (THEOPHILUS).     THE  SCIENCE  AND  ART  OF  OBSTETRICS. 

Third  edition      In  one  handsome  octavo  volume  of  677  pages,  with  267  engravings  and 
2  colored  plates.     Cloth,  $4.25  ;  leather,  $5  25. 

PAVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION,  ITS 
DISORDERS  AND  THEIR  TREATMENT.  From  the  second  London  edition. 
In  one  8vo.  volume  of  238  pages.     Cloth,  $2. 

PAYNE  (JOSEPH  FRANK).  A  MANUAL  OF  GENERAL  PATHOLOGY. 
Designed  as  an  Introduction  to  the  Practice  of  Medicine.  In  one  octavo  volume  of  524 
pages,  with  153  engravings  and  1  colored  plate.     Cloth,  $3.50. 

PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo  volume  of  511  pages, 
with  81  engravings.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  14. 

PICK  (T.  PICKERING).    FRACTURES  AND  DISLOCATIONS.    In  one  12mo. 

volume  of  530  pages,  with  93  engravings.    Cloth,  $2.    See  Series  of  Clinical  Manuals,  p.  13. 

PIRRIE  (WILLIAM) .     THE  PRINCIPLES  AND  PRA CTICE  OF  SURGER  Y. 

In  one  octavo  volume  of  780  pages,  with  316  engravings.     Cloth,  $3. 75. 

PLAYFAIR  (W.  S.\  A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE 
OF  MIDWIFERY.  Sixth  American  from  the  eighth  English  edition.  Edited,  with 
additions,  by  R.  P.  Harris,  M.D.  In  one  octavo  volume  of  697  pages,  with  217  engrav- 
ings and  5  plates.     Cloth,  $4 ;  leather,  $5. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION  AND 


HYSTERIA.     In  one  12mo.  volume  of  97  pages.     Cloth,  $1. 


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12  LEA    BROTHERS    &     CO.'  S    PUBLICATIONS. 

POLITZER  (ADAM).    A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 

AND  ADJACENT  ORGANS.  Second  American  from  the  third  German  edition. 
Translated  by  Oscar  Dodd,  M.D ,  and  edited  by  Sir  William  Dalby,  F.R.CS.  In 
one  octavo  volume  of  748  pages,  with  330  original  engravings.     Cloth,  §5.50. 

POWER  (HENRY).  HUMAN  PHYSIOLOGY.  Second  edition.  In  one  12mo. 
volume  of  396  pages,  with  47  engravings.  Cloth,  §1.50.  See  Students  Series  of  Manuals, 
page  14. 

PURDY  (CHARLES  W.).  BRIGHT' S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.    Cloth,  82 

PYE-SMITH  (PHILIP  H.).  DISEASES^  OF  THE  SKIN.  In  one  12mo=  volume 
of  407  pages,  with  28  illustrations,  18  of  which  are  colored.     Cloth,  §2. 

QUIZ  SERIES.     See  Students'  Quiz  Series,  page  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
of  314  pages,  with  16  engravings.     Cloth,  SI. 50.     See  Students'  Series  of  Manuals,  page  14. 

RAMSBOTHAM  FRANCIS  H.l.     THE  PRINCIPLES  AND  PRACTICE  OF 

OBSTETRIC  MEDICINE  AND  SURGERY  In  one  imperial  octavo  volume  of 
640  pages,  with  64  plates  and  numerous  engravings  in  the  text.     Strongly  bound  in 

leather,  87. 

REICHERT    (EDWARD    T.).     A    TEXT-BOOK   ON  PHYSIOLOGY.     In  one 

handsome  octavo  volume  of  about  800  pages,  richly  illustrated.     Preparing. 

REMSEN    (IRA).     THE  PRINCIPLES  OF  THEORETICAL    CHEMISTRY. 

Fourth  edition,  thoroughlv  revised  and  much  enlarged.     In  one  12mo.  volume  of  325 
Cloth,  §2 


REYNOLDS  (J.  RUSSELL).  A  SYSTEM  OF  MEDICINE.  Edited,  with  notes 
and  additions,  by  ECexry  Hartshorxe,  M.D.  In  three  large  8vo.  volumes,  containing 
3056  closely  printed  double-columned  pages,  with  317  engravings.  Per  volume,  cloth,  $5 ; 
leather,  §6. 

RICHARDSON   (BENJAMIN  WARD).    PREVENTIVE  MEDICINE.    In  one 

octavo  volume  of  729  pages.     Cloth,  §4 ;  leather,  §5. 

ROBERTS  f  JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  In  one  octavo  volume  of  780  pages,  with  501  engravings.  Cloth,  §4.50; 
leather,  $5.50. 

THE  COMPEND  OF  ANATOMY.     For  use  in  the  Dissecting  Room  and  in 


preparing  for  Examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 

ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES,  INCLUDING  URINARY  DEPOSITS.  Fourth 
American  from  the  fourth  London  edition.  In  one  very  handsome  Svo.  volume  of  609 
pages,  with  81  illustrations.     Cloth,  $3.50. 

ROBERTSON  (J.  McGREGOR'.    PHYSIOLOGICAL  PHYSICS.    In  one  12mo. 

volume  of  537  pages,  with  219  engravings.     Cloth,  $2.     See  Students'  Series  of  Manuals, 
page  14. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE  NERVOUS 
SYSTEM.  In  one  handsome  octavo  volume  of  726  pages,  with  184  engravings.  Cloth, 
§4.50;  leather,  §5.50. 

SAVAGE  (GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES,  PRACTI- 
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ings.    Cloth,  §2.     See  Series  of  Clinical  Manuals,  page  13.       • 

SCHAFER  (EDWARD  A.  I .  THE  ESSENTIALS  OF HISTOL OGY,  DESCRIP- 
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handsome  octavo  volume  of  311  pages,  with  2S8  illustrations.     Cloth,  $3. 


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SCHREIBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY  MASSAGE 
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SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edition.  In  one 
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SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  INFANCY 
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SOLLY    (S.    EDWIN).     A    HANDBOOK    OF   MEDICAL    CLIMATOLOGY. 

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Surgical  Pathology,  $2;  Treves'  Surgical  Applied  Anatomy,  $2;  Power's  Human 
Physiology  (2d  edition),  $1.50;  Ralfe's  Clinical  Chemistry,  $1.50;  and  Clarke  and 
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For  separate  notices,  see  under  various  authors'  names. 

STUROES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY  OF  CLIN- 
ICAL MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

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Appropriate  Treatment.  In  one  8vo.  volume  of  526  pages,  with  250  engravings  and 
9  full-page  plates.     Cloth,  $4.50. 

TAIT  (LAWSON).    DISEASES  OF  WOMEN  AND  ABDOMINAL  SURGERY. 

In  two  handsome  octavo  volumes.  Vol.  1.  contains  546  pages  and  3  plates.  Cloth,  $3. 
Vol.  II.,  'preparing. 

TANNER  (THOMAS  HAWKES*.  ON  THE  SIGNS  AND  DISEASES  OF 
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TAYLOR  (ALFRED  S.).  MEDICAL  JURISPRUDENCE.  Eleventh  American 
from  the  twelfth  English  edition,  specially  revised  by  Clark  Bell,  Esq.,  of  the  N.  Y. 
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TAYLOR  (ROBERT  W.).  THE  PATHOLOGY  AND  TREATMENT  OF 
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THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  P.).  A  PRACTICAL 
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THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DISEASES  OF 
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203  pages,  with  25  engravings.     Cloth,  $2.25. 

THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREATMENT  OF 
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third  English  edition-  In  one  octavo  volume  of  359  pages,  with  47  engravings  and  3 
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TODD  (ROBERT  BENTLEY).  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.     In  one  8vo.  volume  of  320  pages.    Cloth,  $2.50. 

TREVES  (FREDERICK ».  OPERATIVE  SURGERY.  In  two  8vo.  volumes  con- 
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467  pages,  with  2  colored  plates.     Cloth,  $3. 

VAUGHAN  (VICTOR  C.)  AND  NOVY  (FREDERICK  G.).  PTOMAINS, 
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190  engravings.     Cloth,  §9  ;  leather,  $11. 

WELLS  (J.  SOELBERG).  A  TREATISE  ON  THE  DISEASES  OF  THE 
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WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR  TO 
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ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 


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WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT,  OR  THERA- 
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